What Is Epididymitis?

Scrotal pain is a common concern in people assigned male at birth attending the emergency department. It can be an indication of several different conditions affecting the testes, scrotum, or surrounding structures. Of these conditions, epididymitis is the most frequent diagnosis.¹ 

Epididymitis, most common in men aged 19 to 35, is an inflammatory condition of the epididymis (a small tube behind the testicle which holds and transports sperm).² It presents as pain and swelling in the scrotum, usually caused by an infection, and is typically treated with antibiotics.³ 

If you are concerned that you or someone in your care is currently suffering with epididymitis, all the relevant information regarding the symptoms, diagnosis and treatment of the condition can be found in this article. 

Figure 1: Diagram of the structure of the testis. Source: Wiki Commons. 

Overview

One of the main causes of scrotal pain is epididymitis. The epididymis is a tubular structure attached to the testis that is responsible for storing and transporting sperm. Although it is only 6 - 7cm long, it can cause a significant amount of pain when it becomes inflamed. In any instance, if scrotal pain occurs, it is important to visit a healthcare provider urgently in case of testicular torsion.

Causes of epididymitis

The causes of epididymitis typically vary depending on age. 

Repetitive movements caused by playing sports or physical trauma to the scrotal area can cause epididymitis in younger, sexually inactive people with penises. Additionally, in this age group, bacterial infections such as E.coli, which can be present in the urinary tract, may spread further to the epididymis and cause epididymitis.^2,4

In sexually-active individuals, epididymitis is usually caused by sexually transmitted infections (STIs) such as Chlamydia trachomatis or Neisseria gonorrhoea.

Individuals above the age of 35 years may experience retrograde flow of urine from the bladder or urethra - this is when urine flows in the opposite direction to normal flow. It can occur when there is prostatic enlargement. Infected urine can then spread to other parts of the genitourinary tract and cause epididymitis.³ The bacteria responsible for most infections in this age group is E.coli.² 

Other less common causes include:⁵

• A complication of Mumps (a viral infection)
• As a rare side effect of the medication Amiodarone
• Retrograde flow of urine due to sexual intercourse with a full bladder
• Other bacteria including Mycobacterium tuberculosis 

Signs and symptoms of epididymitis 

Symptoms of epididymitis may include^{3, 6}:

• Gradual onset of scrotal pain or flank pain that moves to the scrotum
• Palpable swelling around the testes
• Pain when urinating, increased urinary frequency or urinary incontinence
• Urethral discharge
• Elevated temperature 

When symptoms come on gradually and last for fewer than three months, it is referred to as acute epididymitis.³ 

In many cases, epididymitis may also occur in conjunction with inflammation of the testis. This is known as epididymo-orchitis. Symptoms of epididymo-orchitis include: ⁴

• Tenderness of the testis upon physical examination
• Warmth and/or redness of the skin of the scrotum
• Swollen or tender lymph nodes in the groin 
• Urethral discharge
• Tender prostate gland when examined 

Management and treatment for epididymitis

The mainstay of epididymitis treatment is antibiotic therapy. Depending on the confirmed or suspected underlying cause, your healthcare provider will prescribe the appropriate course of medication. As the actual causative organism may not be known until laboratory tests are complete, empiric antibiotic therapy is usually initiated to prevent a delay in treatment. This is when the healthcare provider will prescribe medication based on the most likely cause as any delay in treatment can cause considerable complications. They may also recommend that you attend a sexual health clinic and contact all sexual partners so that they can also be treated in cases where an STI is suspected. 

As in all situations where antibiotics are prescribed, it is important to complete the entire course of medication to reduce the risk of recurrence and complications. 

Other supportive therapies for the treatment of epididymitis include: ⁴

• Rest from repetitive activity
• Anti-inflammatory medications 
• Supportive underwear 

Symptoms of epididymitis should begin to improve within a few days of treatment and most cases do not require hospitalisation. If you do not experience some improvement in the level of pain or swelling with medication, or your symptoms worsen, you should contact your healthcare provider urgently. 

Upon successful completion of treatment, further specialist investigations may still be recommended by your healthcare provider to allow the identification of any underlying urological issues which could have contributed to the development of epididymitis.³ 

Diagnosis of epididymitis

If you are suffering with scrotal pain or suspect that you have epididymitis, you should see your healthcare provider. They can take a complete history of your symptoms and perform a physical examination or additional testing These tests may include:¹

• Blood tests including a full blood count
• Urinalysis to quickly obtain a reliable indication of the presence of infection in the urinary tract
• Urine microscopy and culture to identify the causative organisms and determine the most effective antibiotics against them
• Urethral swabs to test for sexually transmitted diseases (C.trachomatis and N.gonorrhoea)
• Imaging of the scrotum to exclude other diagnoses

It is important that testicular torsion, which is a surgical emergency, is not missed during the physical examination. This is where the spermatic cord becomes twisted leading to reduced blood flow to the testis. This can lead to irreversible damage to the testis.³ 

Risk factors

Risk factors for epididymitis include:^{3, 7} 

• Recurrent urinary tract infections and sexually transmitted infections 
• Anal intercourse
• Recent surgery of urinary tract (e.g. prostate)
• Injury to the scrotal region
• Prolonged sitting (e.g. cycling)
• Catheterisation

Complications

In instances where treatment is unsuccessful or delayed, the condition may progress into the following:

• Sepsis 
• Epididymo-orchitis  
• Epididymal abscess
• Infertility 

If epididymitis persists for more than 3 months, it is referred to as chronic epididymitis. In comparison to acute epididymitis, this usually involves scrotal pain without swelling but can also cause chronic pain in the groin, thigh and lower back. Your healthcare provider will be able to help you manage this condition.⁸ 

FAQs

How can I prevent epididymitis?

• Practice safe sex (e.g. wear condoms during sexual intercourse)
• Avoid sitting for prolonged periods and heavy lifting⁹

How common is epididymitis?

The UK incidence of epididymitis in adults with penises is between 25 to 65 per 10,000 annually.⁶

When should I see a doctor?

If you experience any of the symptoms of epididymitis mentioned in this article, you should see a healthcare provider as soon as possible so that a prompt diagnosis can be made. The sooner epididymitis is identified, the quicker the treatment can be started and the lower the risk of complications.

Summary

It is important to see a healthcare provider if you experience scrotal pain or swelling. A delay in treatment can lead to a poorer outcome or serious complications. With early diagnosis and adherence to antibiotic treatment, epididymitis is a treatable condition with a good prognosis.