Symptoms of Epididymitis
Epididymitis typically presents with gradual onset of unilateral testicular pain and tenderness, with palpable swelling of the epididymis that usually begins at the lower pole and progresses upward toward the upper pole of the testis. 1, 2
Core Clinical Presentation
The hallmark symptoms vary by age and etiology but share common features:
- Testicular pain: Unilateral, gradual onset over hours to days (not sudden), located posteriorly in the scrotum 1, 3
- Epididymal swelling and tenderness: Palpable enlargement starting at the lower pole, progressing to the upper pole 1, 4
- Scrotal swelling and erythema: May develop as inflammation progresses 1
- Elevated scrotal temperature: Local warmth over the affected area 1
Associated Urogenital Symptoms
In Younger Men (<35 years)
- Urethritis symptoms (often asymptomatic): Urethral discharge, dysuria, or urinary frequency may accompany sexually transmitted epididymitis 1, 5
- Lower abdominal or groin pain: Extension of inflammatory process 2
In Older Men (>35 years)
- Urinary tract symptoms: Dysuria, urinary frequency, urgency, weak stream, or hesitancy related to bladder outlet obstruction 1, 3, 4
- Palpable bladder: May indicate urinary retention 4
Key Distinguishing Clinical Signs
- Prehn sign (positive): Pain relief when elevating the scrotum over the symphysis pubis, helping differentiate from testicular torsion 1, 3
- Reactive hydrocele: May develop as inflammation and edema progress 1
- Fever: Can occur in severe cases, indicating systemic involvement 1
Critical Timing Characteristics
The onset is insidious and gradual over 1-2 days, NOT sudden 1, 3. This temporal pattern is crucial for distinguishing epididymitis from testicular torsion, which presents with sudden, severe pain requiring emergency surgical intervention within 4-6 hours 5, 4.
Age-Specific Symptom Patterns
Men <35 Years (Sexually Active)
- Often minimal urinary symptoms despite urethritis 2
- May have recent new sexual partner or unprotected intercourse 5
- Penile discharge or dysuria if present 2
Men >35 Years
- More prominent lower urinary tract symptoms 1, 3
- History of recent urinary instrumentation, surgery, or known prostatic disease 1, 4
Systemic Symptoms Requiring Urgent Evaluation
- Severe pain: Inability to ambulate or perform daily activities 4
- Systemic illness: High fever, rigors, nausea, vomiting indicating possible abscess or Fournier's gangrene 1, 4
- Scrotal skin changes: Crepitus, necrosis, or rapidly spreading erythema suggesting necrotizing infection 1
Common Diagnostic Pitfalls
Do not rely solely on absence of urinary symptoms to exclude epididymitis in younger men, as sexually transmitted epididymitis frequently presents without significant pyuria or urinary complaints 2. The infection originates from urethral pathogens, not urinary tract bacteria, making urethral swab testing essential rather than just urinalysis 5, 2.