What are the symptoms, causes, and treatments of epididymitis vs testicular torsion?

Epididymitis vs. Testicular Torsion: Symptoms, Causes, and Treatment

Testicular torsion is a surgical emergency requiring immediate intervention, while epididymitis is typically managed with antibiotics and supportive care. 1

Key Differences in Presentation

Epididymitis

• Onset: Gradual onset of posterior scrotal pain
• Age: Most common in men >35 years (enteric bacteria) or 14-35 years (sexually transmitted)
• Associated symptoms: Often accompanied by urinary symptoms (dysuria, frequency)
• Physical findings:
  • Swollen and tender epididymis
  • Testis in normal anatomic position
  • Intact cremasteric reflex
  • Pain relief with testicular elevation (positive Prehn sign)
  • Fever may be present

Testicular Torsion

• Onset: Sudden, severe scrotal pain
• Age: More common in adolescents
• Associated symptoms: Nausea and vomiting common; urinary symptoms typically absent
• Physical findings:
  • High-riding testis
  • Abnormal testicular position
  • Absent cremasteric reflex
  • No relief with testicular elevation (negative Prehn sign)
  • Minimal fever

Causes

Epididymitis

• Age <14 years: Primarily reflux of urine into ejaculatory ducts 2
• Age 14-35 years: Primarily sexually transmitted infections
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis 1
• Men who practice insertive anal intercourse: Enteric organisms 1
• Age >35 years: Primarily enteric bacteria from urinary reflux due to bladder outlet obstruction 2, 3
• Immunocompromised patients: Higher risk of fungal and mycobacterial infections 1

Testicular Torsion

• Anatomical predisposition (bell-clapper deformity)
• Trauma
• Rapid growth during puberty
• Cryptorchidism
• Previous episodes of torsion 4, 5

Diagnostic Approach

Clinical Assessment

When evaluating acute scrotal pain, focus on:

1. Age: Torsion more common in adolescents; epididymitis more common in adults
2. Onset timing: Sudden (torsion) vs. gradual (epididymitis)
3. Duration of symptoms: Torsion typically <24 hours; epididymitis often >24 hours 5
4. Urinary symptoms: Present in epididymitis, typically absent in torsion

Laboratory Testing

• Urethral Gram stain: For urethritis diagnosis (≥5 PMNs per oil immersion field) 1
• Urethral culture or nucleic acid amplification test: For N. gonorrhoeae and C. trachomatis 1
• First-void urine: For leukocytes if urethral Gram stain is negative 1
• Urine culture: For enteric organisms 1

Imaging

• Doppler ultrasound:
  • Epididymitis: Increased blood flow
  • Torsion: Decreased or absent blood flow 6, 5
• Note: If testicular torsion is strongly suspected clinically, do not delay surgical exploration for imaging studies 7

Treatment

Epididymitis

Based on likely causative organisms:

1. For ages 14-35 years (likely STI pathogens):

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

2. For men who practice insertive anal intercourse (enteric organisms):

   • Ceftriaxone 250 mg IM single dose PLUS
   • Levofloxacin 500 mg orally once daily for 10 days OR
   • Ofloxacin 300 mg orally twice daily for 10 days 1

3. For men >35 years (likely enteric organisms):

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

4. Supportive care:

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

Testicular Torsion

• Immediate urological consultation and surgical exploration
• Time-critical: Testicular salvage rates decrease significantly after 6 hours of torsion
• Surgical management: Detorsion and bilateral orchiopexy 4, 7

Follow-Up and Complications

Epididymitis

• Follow-up: If no improvement within 3 days, reevaluate diagnosis and therapy 1
• Partner management: For STI-related cases, refer partners within 60 days of symptom onset 1
• Complications: Infertility, chronic scrotal pain, abscess formation 2

Testicular Torsion

• Complications: Testicular atrophy, infertility, chronic pain 6
• Salvage rates: Approximately 80-90% if treated within 6 hours; <10% after 24 hours 5

Critical Pitfalls to Avoid

1. Misdiagnosing testicular torsion as epididymitis - this can lead to testicular loss
2. Delaying surgical exploration when torsion is suspected - do not wait for imaging if clinical suspicion is high
3. Failing to consider age-appropriate pathogens when treating epididymitis
4. Inadequate follow-up - patients with epididymitis should improve within 3 days of appropriate therapy
5. Overlooking partner treatment in STI-related epididymitis cases

Remember that testicular torsion is a time-sensitive surgical emergency, while epididymitis typically responds well to appropriate antibiotic therapy and supportive care.