What are the signs of epididymorchitis in a male?

Signs of Epididymo-orchitis in Males

Men with epididymo-orchitis typically present with unilateral testicular pain and tenderness, with hydrocele and palpable swelling of the epididymis usually present. 1

Classic Clinical Presentation

The hallmark features of epididymo-orchitis include:

• Unilateral testicular pain and tenderness that develops gradually over hours to days, distinguishing it from the sudden onset seen in testicular torsion 1, 2
• Palpable swelling of the epididymis that typically starts at the lower pole and progresses toward the upper pole of the testis 3
• Hydrocele formation commonly accompanies the inflammatory process 1
• Scrotal skin thickening and erythema may be visible on examination 4

Associated Symptoms

Beyond the primary testicular findings, patients frequently experience:

• Urinary symptoms including dysuria and urinary frequency, particularly in older men with enteric organism infections 2
• Fever when the infection is more severe or complicated 1, 5
• Urethral discharge in younger men with sexually transmitted infections 1

Physical Examination Findings

The examination reveals specific characteristics:

• Swollen, tender testis with the testis remaining in anatomically normal position (unlike torsion where abnormal lie may be present) 2
• Epididymal enlargement that is palpable and exquisitely tender 3
• Positive Prehn sign (pain relief with testicular elevation) may help distinguish from torsion, though this is not entirely reliable 6
• Scrotal wall edema and warmth over the affected hemiscrotum 4

Laboratory Evidence of Inflammation

Diagnostic workup typically demonstrates:

• Pyuria on urinalysis with >5 polymorphonuclear leukocytes per high-power field in urethral smear or first-void urine 1
• Positive urethral Gram stain showing >5 WBCs per oil immersion field, indicating urethritis 1
• Leukocytosis in severe or systemic cases 5

Age-Specific Patterns

The clinical presentation varies by age group:

• Men <35 years: More likely to have sexually transmitted pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae) with associated urethritis symptoms 7, 2
• Men ≥35 years: More commonly have enteric organisms (E. coli) related to bladder outlet obstruction or recent urinary instrumentation 1, 8, 2

Critical Red Flags Requiring Immediate Evaluation

Severe pain, hard testicle, and new-onset fever suggest complicated epididymo-orchitis with potential abscess formation, testicular infarction, or alternatively delayed testicular torsion. 5 These findings mandate:

• Immediate urological consultation as testicular torsion remains a surgical emergency even with apparent inflammatory signs 5, 6
• Doppler ultrasound evaluation showing increased blood flow to the epididymis and testis (hyperemia) in epididymo-orchitis, versus decreased/absent flow in torsion 4, 6
• Hospitalization consideration for patients with severe pain, fever, or when compliance with outpatient antibiotics is questionable 1

Common Diagnostic Pitfalls

Be aware that:

• Testicular torsion must always be excluded first, as it occurs more frequently in patients without evidence of inflammation or infection 1, 6
• Emergency testing for torsion is indicated when pain onset is sudden, pain is severe, or initial tests don't support urethritis/UTI diagnosis 1, 4
• Failure to improve within 3 days of antibiotic therapy requires comprehensive reevaluation for alternative diagnoses including tumor, abscess, infarction, or tuberculous/fungal infection 1, 5