What is epididymitis, a testicular infection?

Epididymitis: A Testicular Infection

Epididymitis is an inflammation of the epididymis, most commonly caused by bacterial infection, which can spread to the testis (epididymo-orchitis) if left untreated, potentially leading to infertility and chronic scrotal pain. 1

Clinical Presentation

• Symptoms:

  • Unilateral testicular pain and tenderness with gradual onset
  • Palpable swelling of the epididymis
  • Hydrocele may be present
  • May be accompanied by urinary symptoms (dysuria, frequency)
  • Often associated with urethritis (which may be asymptomatic)

• Physical Findings:

  • Swollen and tender epididymis
  • Testis in anatomically normal position
  • Prehn sign: pain relief with testicular elevation (distinguishes from testicular torsion)
  • Cremasteric reflex present (absent in torsion)

Etiology Based on Age

1. Men <35 years old:

   • Most commonly caused by sexually transmitted infections:
     • Chlamydia trachomatis
     • Neisseria gonorrhoeae
   • In men who practice insertive anal intercourse: enteric organisms (E. coli) 1

2. Men >35 years old:

   • Usually caused by gram-negative enteric bacteria
   • Often associated with:
     • Urinary tract infections
     • Bladder outlet obstruction
     • Recent urinary tract instrumentation or surgery
     • Anatomical abnormalities 1

3. Children (prepubertal):

   • Often related to reflux of urine into ejaculatory ducts
   • Underlying urinary tract abnormalities 2

Diagnostic Evaluation

The following procedures are essential for proper diagnosis:

1. Urethral evaluation:

   • Gram-stained smear of urethral exudate (>5 PMNs per oil immersion field indicates urethritis)
   • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis

2. Urine studies:

   • First-void urine examination for leukocytes if urethral Gram stain is negative
   • Culture and Gram-stained smear of uncentrifuged urine

3. Additional testing:

   • Syphilis serology
   • HIV counseling and testing 1

Critical Differential Diagnosis

Testicular torsion must be ruled out in all cases, especially in:

• Adolescents
• Patients with sudden onset of severe pain
• Patients without evidence of inflammation/infection
• Cases with high-riding testis or absent cremasteric reflex

If torsion is suspected, immediate specialist consultation is required as testicular viability may be compromised within hours. 1

Treatment Algorithm

1. For epididymitis likely caused by STIs (men <35 years):

• Ceftriaxone 250 mg IM in a single dose
• PLUS
• Doxycycline 100 mg orally twice daily for 10 days 1

2. For epididymitis likely caused by enteric organisms (men >35 years, insertive anal intercourse, or allergies to above medications):

• Ofloxacin 300 mg orally twice daily for 10 days
• OR
• Levofloxacin 500 mg orally once daily for 10 days 1

3. Adjunctive measures:

• Bed rest
• Scrotal elevation
• Analgesics
• Continue until fever and local inflammation subside 1

Management of Sexual Partners

• For cases caused by STIs, refer all sexual partners from the past 60 days for evaluation and treatment
• Advise abstinence from sexual intercourse until both patient and partner(s) complete treatment and are symptom-free 1

Follow-Up and Complications

• Re-evaluation is necessary if no improvement within 3 days

• Persistent swelling or tenderness after treatment requires comprehensive evaluation for:

  • Tumor
  • Abscess
  • Testicular infarction
  • Testicular cancer
  • Tuberculous or fungal epididymitis 1

• Potential complications if untreated:

  • Infertility (affects approximately 40% of patients)
  • Chronic scrotal pain
  • Abscess formation
  • Testicular ischemia 2, 3

Special Considerations

HIV Infection

• Same treatment regimen as HIV-negative patients for uncomplicated cases
• Higher risk of fungal and mycobacterial causes in immunosuppressed patients 1

Recurrent Epididymitis

• Thorough examination for subvesical obstruction
• Some patients may benefit from prophylactic vasectomy in recurrent cases 3

Key Pitfalls to Avoid

1. Misdiagnosing testicular torsion as epididymitis (surgical emergency requiring immediate intervention)
2. Inadequate treatment duration (full 10-day course needed even if symptoms improve)
3. Failing to evaluate and treat sexual partners in STI cases
4. Not considering resistant organisms in patients with indwelling catheters (may require broader coverage)
5. Missing underlying anatomical abnormalities in older men and children

By following this structured approach to diagnosis and treatment, the risk of complications such as infertility and chronic pain can be significantly reduced.