Can Epididymitis Lead to Pyuria?
Yes, epididymitis can lead to pyuria, but the presence and significance of pyuria varies dramatically by age and etiology—in sexually active men aged 14-35 years, pyuria is commonly present as part of the infectious/inflammatory process, while in prepubertal boys, pyuria is notably absent in the vast majority of cases (96-99%), making it an unreliable finding in this population. 1, 2, 3
Age-Dependent Relationship Between Epididymitis and Pyuria
In Sexually Active Adults (14-35 Years)
Pyuria is an expected finding in this population because epididymitis is most commonly caused by sexually transmitted pathogens (N. gonorrhoeae and C. trachomatis), which typically cause concurrent urethritis 1, 4
The CDC guidelines explicitly recommend examining first-void uncentrifuged urine for leukocytes as part of the diagnostic evaluation, indicating pyuria is a clinically relevant finding 1, 4
A Gram-stained smear showing ≥5 polymorphonuclear leukocytes per oil immersion field in urethral exudate or urine confirms urethritis, which commonly accompanies sexually transmitted epididymitis 1, 4
In Men Over 35 Years
Pyuria is frequently present because epididymitis in this age group is typically caused by enteric Gram-negative organisms associated with urinary tract infections secondary to bladder outlet obstruction 1, 5
Urine culture and Gram-stained smear for Gram-negative bacteria are recommended diagnostic procedures 1
The presence of pyuria in this population supports the diagnosis and guides antibiotic selection toward fluoroquinolones (levofloxacin or ofloxacin) that cover enteric pathogens 1, 5
In Prepubertal Boys (Under 14 Years)
Pyuria is notably ABSENT in 96-99% of cases, making it an unreliable diagnostic marker in this population 6, 2, 3
In a study of 76 children with epididymitis, 73 cases (96.1%) had negative pyuria on urinalysis, and the most common etiology was idiopathic 2
Another study of 93 prepubertal boys found only 1 patient (1%) with bacteriuria in urine sediment, and all urine cultures were sterile 3
The etiology in prepubertal boys is largely unknown but thought to involve reflux of sterile urine into the ejaculatory ducts rather than bacterial infection 5, 6
Clinical Implications for Diagnosis and Treatment
When Pyuria is Present
In adults, the presence of pyuria supports the diagnosis of infectious epididymitis and indicates need for antimicrobial therapy 1, 4
Pyuria with positive urine culture in any age group warrants antibiotic treatment 2, 3
When Pyuria is Absent
In prepubertal boys without pyuria, antibiotics are NOT indicated—supportive therapy with rest, scrotal elevation, and analgesics is sufficient 6, 2, 3
In adults, absence of pyuria should prompt examination of first-void urine and urethral specimens, as sexually transmitted epididymitis may still be present with urethritis 1, 4
Common Pitfalls to Avoid
Do not assume all epididymitis requires antibiotics—in prepubertal boys with negative urine studies, the condition is self-limiting and does not lead to testicular atrophy 6, 3
Do not skip urinalysis in adults—pyuria helps differentiate sexually transmitted from enteric causes and guides appropriate antibiotic selection 1, 4, 5
Do not overlook testicular torsion—this surgical emergency must be ruled out in all cases, especially when pyuria is absent and pain onset is sudden 1, 4
In children with epididymitis showing pyuria (rare but possible), antibiotics should be considered as this suggests true bacterial infection 2, 3