What is epididymitis?

Epididymitis: Definition and Management

Epididymitis is an inflammation of the epididymis, typically caused by bacterial infection, characterized by unilateral testicular pain and tenderness with palpable swelling of the epididymis. 1

Clinical Presentation and Diagnosis

Symptoms and Signs

• Gradual onset of unilateral scrotal pain
• Swelling and tenderness of the epididymis
• May be accompanied by urinary symptoms (dysuria, frequency)
• Pain relief with testicular elevation (positive Prehn sign)
• Normal testicular position with present cremasteric reflex 1

Key Diagnostic Features to Differentiate from Testicular Torsion

Feature	Epididymitis	Testicular Torsion
Onset	Gradual	Sudden
Pain relief with elevation	Yes (Prehn sign)	No
Cremasteric reflex	Present	Absent
Testicular position	Normal	High-riding
Doppler ultrasound	Increased blood flow	Decreased/absent blood flow

Diagnostic Evaluation

• Urethral swab or first-void urine for STI testing
• Gram-stained smear of urethral exudate for N. gonorrhoeae and NGU
• Urinalysis and urine culture for Gram-negative bacteria
• Scrotal ultrasound with Doppler to rule out torsion, masses, or confirm epididymitis 2, 1

Etiology

Age-Based Etiology

1. Men <35 years:

   • Most commonly caused by sexually transmitted infections (STIs)
   • Primary pathogens: Neisseria gonorrhoeae and Chlamydia trachomatis 2, 1, 3
   • E. coli in men who are insertive partners during anal intercourse 2

2. Men >35 years:

   • Usually caused by enteric bacteria
   • Often associated with urinary tract infections
   • Frequently related to underlying conditions:
     • Bladder outlet obstruction
     • Benign prostatic hyperplasia
     • Urethral stricture disease
     • Recent urinary tract instrumentation or surgery 1, 3

Treatment

First-Line Treatment

• For men <35 years (STI suspected):

  • Ceftriaxone 250 mg IM single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 2, 1, 4

• For men >35 years (enteric bacteria suspected):

  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1, 3

Alternative Regimens

• Ofloxacin 300 mg orally twice daily for 10 days (contraindicated in patients ≤17 years) 2, 1

Supportive Measures

• Bed rest and scrotal elevation until fever and local inflammation subside
• Non-steroidal anti-inflammatory drugs for pain management 2, 1

Follow-Up and Complications

Treatment Response

• Clinical improvement should occur within 3 days of starting treatment
• If no improvement is seen within 3 days, reevaluation of diagnosis and therapy is required
• Consider hospitalization if condition worsens 2, 1

Persistent Symptoms

• Swelling and tenderness that persist after completing antibiotics require evaluation for:
  • Testicular cancer
  • Abscess formation
  • Tuberculous or fungal epididymitis 2, 1

Potential Complications

• Abscess formation
• Testicular ischemia
• Infertility
• Chronic scrotal pain 1

Partner Management

• Sexual partners of patients with STI-related epididymitis should be referred for evaluation and treatment
• Partners should be treated if contact occurred within 30-60 days preceding symptom onset
• Both patient and partners should avoid sexual intercourse until treatment is completed and all are symptom-free 2, 1

Special Considerations

• HIV-positive patients: Same regimens as for HIV-negative patients, but with higher suspicion for fungal and mycobacterial causes 1
• Warning signs requiring immediate surgical exploration: Sudden onset of severe unilateral scrotal pain, nausea/vomiting, high-riding testicle, and absent cremasteric reflex (suggestive of testicular torsion) 1