What are the causes of chronic epididymitis?

Causes of Chronic Epididymitis

The primary causes of chronic epididymitis (lasting more than 3 months) include sexually transmitted infections, urinary tract infections with enteric organisms, urinary reflux into ejaculatory ducts, anatomical abnormalities, and fungal or mycobacterial infections in immunocompromised patients.

Age-Related Etiologies

In Men Under 35 Years

• Sexually transmitted infections are the predominant cause in this age group 1
  • Chlamydia trachomatis is the most common pathogen 1
  • Neisseria gonorrhoeae is the second most common sexually transmitted cause 1
• These infections are often accompanied by urethritis, which may be asymptomatic 2
• Men who practice insertive anal intercourse are at risk for epididymitis caused by enteric organisms (e.g., Escherichia coli) 2, 1

In Men Over 35 Years

• Urinary tract infections with gram-negative enteric bacteria are the most common cause 1
• Escherichia coli is the predominant pathogen in this age group 3
• Often associated with:
  • Bladder outlet obstruction 3
  • Benign prostatic hyperplasia 3
  • Recent urinary tract instrumentation or surgery 2
  • Anatomical abnormalities of the urinary tract 2, 4

In Children and Adolescents

• Reflux of urine into the ejaculatory ducts is considered the most common cause 1
• Congenital genitourinary abnormalities should be excluded by imaging 5

Special Considerations

Chronic Epididymitis

• Defined as epididymal pain and inflammation persisting for more than 3 months 6
• May present with unilateral or bilateral testicular, epididymal, or scrotal pain as the sole symptom 6
• Can lead to significant morbidity including:
  • Chronic scrotal pain 1
  • Potential infertility if left untreated 1

In Immunocompromised Patients

• Fungal infections are more likely to cause epididymitis in immunosuppressed patients 2
• Mycobacterial infections, particularly tuberculosis, can present as epididymitis 2, 5
• HIV-infected patients should receive the same initial treatment as HIV-negative patients, but with awareness of the higher likelihood of fungal or mycobacterial etiology 2

Diagnostic Approach

• Physical examination typically reveals:
  • Swollen, tender epididymis 2
  • Testis in anatomically normal position 1
  • In acute cases, swelling often starts at the lower pole and progresses upward 3
• Urethral evaluation:
  • Gram-stained smear of urethral exudate for diagnosis of urethritis 2
  • Testing for N. gonorrhoeae and C. trachomatis 2
• Urine studies:
  • Examination of first-void urine for leukocytes 2
  • Culture and Gram-stained smear of uncentrifuged urine 2

Clinical Pearls and Pitfalls

• Chronic epididymitis must be distinguished from testicular torsion, which is a surgical emergency requiring intervention within 4-6 hours 3
• Persistent symptoms after appropriate antimicrobial therapy warrant comprehensive evaluation for other conditions including tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 2
• Untreated acute epididymitis can progress to chronic epididymitis, leading to infertility and chronic scrotal pain 1
• In men with recurrent or persistent symptoms, evaluation for underlying structural or functional abnormalities of the urinary tract is essential 4