I. What every physician needs to know.

Epididymitis should be on every astute physician’s short list of differential diagnoses when confronted with the acute scrotum. Epididymitis is classically defined as inflammation, pain and swelling of the epididymis. It can occur secondary to an infectious or noninfectious etiology in the acute or chronic setting. The condition is thought to primarly arise from the retrograde spread of infection from the bladder, prostate or urethra via the ejaculatory ducts and vas deferens to the epididymis. Less frequently, noninfectious causes can be responsible and may include trauma, surgery, amiodarone-induced, and epididymitis associated with a known syndrome such as Behçet’s Disease.

II. Diagnostic Confirmation: Are you sure your patient has Epididymitis?

Although nothing replaces a thorough history and physical, it is worth noting that epididymitis is the most common inflammatory condition of the scrotum. Theoretically, it can occur in any male, although it is most frequently encountered in adolescents and middle-aged men. The disease can occur unilaterally or bilaterally with the former presentation being more common. Some important predisposing factors include recent physical strain, sexual activity/exposure to a sexually transmitted disease, or history of urethral instrumentation/prostatectomy. In pediatric patients, the assessing physician should be mindful of the possibility of an underlying urinary tract infection or congenital anomaly of the genitourinary tract.

A. History Part I: Pattern Recognition:

The typical patient who presents with epididymitis will likely complain of scrotal swelling and pain with or without fevers. The discomfort may radiate to the patients groin, flank or lower abdomen. The patient also may complain of dysuria or have symptoms suggestive of urethritis, cystitis or prostatitis.

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B. History Part 2: Prevalence:

Patients with epididymitis may be stratified into the following groups.

The majority of men under 35 with epididymitis likely contracted the condition secondary to a sexually transmitted disease. Urethritis brought about byChlamydia trachomatis andNeisseria gonorrhoaea accounts for a large proportion of cases.

Men over the age of 35 and pediatric patients most likely have infections from urinary pathogens such as E. coli due to stasis.

Homosexual men who engage in anal intercourse likely are infected by coliform bacteria such as E. coli orHaemophilus influenzae

Causative organisms in immunocompromised individuals include cytomegalovirus. Of note, granulomatous disease arising from tuberculosis, brucellosis, and BCG have also been shown to bring about epididymitis.

Although seldom encountered, epididymitis can be secondary to tuberculosis.

C. History Part 3: Competing diagnoses that can mimic Epididymitis.

By and far the most important diagnosis to differentiate from epididymitis when faced with the acute scrotum is testicular torsion. Testicular torsion is a surgical emergency that when misdiagnosed can result in testicular loss. One may find the torsed testicle to be retracted with an unpalpable spermatic cord upon physical examination. Doppler ultrasound or radionuclide scanning may be used to distinguish between the two entities. However, these studies should not delay surgical exploration if the suspicion for torsion remains high.

Other diagnoses to keep in mind when dealing with the acute scrotum include torsion of the testicular or epididymal appendage, a testicular tumor, or trauma. A patient with torsion of the appendages usually present with intermittent pain localized to the testicle. Testicular tumors may have palpable masses, testicular “fullness” or symptoms of metastatic disease including lumbago or dyspnea. A patient with trauma to the scrotum can typically be identified by a thorough history.

If the discomfort also localizes to the testicles, one must also consider orchitis as a diagnostic possibility.

D. Physical Examination Findings.

A meticulous physical exam will yield a tender edematous epididymis early on. There may be surrounding signs of inflammation such as erythema on the overlying skin. Later in acute process the resulting inflammation may also involve the testis making differentiation of the two structures difficult. If palpated, the spermatic cord may also be tender and swollen. In chronic cases, the epididymis may be thickened and indurated. Diffuse scrotal enlargement may also be present due to a reactive hydrocele. Urethral discharge may be present. A digital rectal exam may yield changes consistent with prostatitis. Care should be taken to avoid a prostatic massage, as this may exacerbate the epididymitis.

E. What diagnostic tests should be performed?

As the cause of epididymitis is usually infectious in origin, it is important to isolate which organisms are responsible for the condition. The initial investigation should incorporate studies which analyze the urine or urethral discharge, if present. Radiographic studies when implemented, are typically used only to confirm the diagnosis.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

It is prudent to begin the diagnostic investigation with a routine urinalysis and urine culture. Pyuria is often found in greater than 90% of cases. If urethral discharge is encountered, a Gram stain may reveal intracellular gram-negative diplococci indicating infection byNeisseria gonorrhoaea.The presence of leukocytes alone points to the diagnosis of nongonococcal urethritis likely secondary toChlamydia trachomatis.If available, serum blood analyses can show elevated white counts. Any infant or young boy diagnosed with epididymitis should receive an abdominopelvic ultrasound, voiding cystourethrography, and possible cystoscopy for further evaluation of any congenital abnormalities. Specifically, an ectopic ureter can insert on any of the Wolffian duct structures.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Radiographic imaging is useful as an adjunct to clinical diagnosis of epididymitis for confirmation. Doppler ultrasonography and radionuclide imaging are two modalities used primarily to detect the presence of blood flow to the testes, which effectively rules out testicular torsion.

On doppler imaging, the classical sign for epididymitis is high flow present throughout an enlarged epididymis. This hyperemia is indicative of inflammation. A normal epididymis will seldom show detectable flow, even when visualized under the lowest possible flow settings. In most patients the epididymis is characterized by uniformly low echogenicity. It is not uncommon to see thickening of the scrotal skin or a reactive hydrocele. A complex fluid collection surrounding the testicle should alert the primary caregiver of a possible pyocele. Focal hypoechoic areas in the epididymis may indicate the existence of an epididymal abscess. Hypoechoic areas in the testicle may hint at the presence of testicular ischemia or orchitis.

Radionuclide imaging uses technetium-99m pertechnetate to assess for presence of blood flow to the epididymis. The radiopharmaceuticals can be administered orally or intravenously. Their presence is detected in the epididymis via external detectors (gamma cameras) which form images from the radiation emitted from the radiopharmaceuticals. High signals from the epididymis would be indicative of epididymitis.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

Doppler ultrasound or radionuclide studies may be used to confirm the diagnosis of testicular torsion or epididymitis in extremely unclear cases. However, they do take time that can be relevant in the setting of testicular torsion requiring surgical exploration. Cost of these studies can be high and their utility is usually debatable. Radionuclide scanning is also not universally available and is certainly not expeditious. A comprehensive history and physical should differentiate the two entities in most cases. Radiographic studies should be saved for those situations where the diagnosis is less certain.

III. Default Management.

Default management of acute epididymitis includes outpatient treatment with oral antibiotics (ciprofloxacin or trimethoprim-sulfamethoxazole) for a duration of 28 days to ensure eradication of the causative organisms. Anti-inflammatory agents, nerve blocks, scrotal elevation/support, bed rest and an ice bag may also be utilized as supportive measures.

Chronic epididymitis should be treated with prolonged antibiotic course of up to 4-6 weeks. The aforementioned supportive measures may also be implemented in these cases. It is widely believed that chronic epididymitis is a self-limiting condition that “burns out”, however, it is worth noting that this process may take years or more. An epididymectomy should be considered only as a last resort as its chances of completely eradicating pain are at best 50%.

Epididymitis secondary to sexually transmitted urethritis should be treated with ceftriaxone initially followed by a 14-21 day course of doxycycline. It is important to identify and treat all sexual partners as well.

Severe infections require hospitalization for closer monitoring and parenteral therapy with ampicillin and gentamicin.

A. Immediate management.

There are no treatment measures which absolutely need to be implemented hours after diagnosis. Although for the comfort of the patient, pain control and antibiotics should commence as soon as realistically possible.

B. Physical Examination Tips to Guide Management.

Epididymitis is typically managed on an outpatient basis and often has a prolonged course to complete resolution. Serial scrotal exams should reveal improvement of clinically localized symptoms such as reduced pain and tenderness. Resolution of erythema on the overlying scrotal skin may also be noted. Any sequelae of STDs should resolve with appropriate management.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

When seen as an outpatient in 2-4 weeks a complete blood count, urinalysis, and urine culture may be performed to ensure resolved leukocytosis and eradication of any offending organisms – however, if clinical resolution has occurred these measures are not necessary.

D. Long-term management.

For resolved cases of acute epididymitis, patients may follow up on an as-needed basis. Chronic epididymitis can present a clinical dilemma for the practitioner as it does not always respond to medical management. Surgical resection with epididymectomy has marginal results at best and can result in worsening of symptoms. Some practitioners are performing spermatic cord nerve ablations and have reported successful outcomes, this however, is not widely practiced.

E. Common Pitfalls and Side-Effects of Management.


IV. Management with Co-Morbidities.


A. Renal Insufficiency.

Renally dose all antibiotics that are primarily cleared by the kidneys. One may also choose a different regimen to bypass this issue.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure.

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No change in standard management.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

No change in standard management.

I. Gastrointestinal or Nutrition Issues.

No change in standard management.

J. Hematologic or Coagulation Issues.

No change in standard management.

K. Dementia or Psychiatric Illness/Treatment.

No change in standard management.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

Patient’s with epididymitis are typically dealt with on an outpatient basis. However, in the event of a severe case requiring inpatient hospitalization and treatment with parenteral antibiotics, clinical progression to more serious pathologies such as sepsis or necrotizing fasciitis can result. Providers should be aware that progression to these more serious conditions can occur.

B. Anticipated Length of Stay.

Epididymitis is seldom if ever managed as an inpatient. Anticipated length of stay for severe cases being managed with parenteral antibiotics is likely 3 to 5 days. This period is used to ensure that the patient’s leukocytosis has resolved, their vitals have stabilized and that no other source is to blame for the patient’s state. After an appropriate course of IV antibiotics the patient may be transitioned to a comparable oral regimen.

C. When is the Patient Ready for Discharge.

The patient may be discharged when any fevers or leukocytosis have resolved and they are able to reliably take oral antibiotics.

D. Arranging for Clinic Follow-up.

Clinic follow up can be arranged in 2-4 weeks for acute epididymitis. Chronic cases can be followed up upon after completion of their long-term antibiotics or every 3 to 6 months to assess for interval change. In all cases patients should return to their urologist or ED if they experience acute worsening in their condition characterized by fevers, chills, nausea, vomiting, inability to void, or uncontrolled pain.

1. When should clinic follow up be arranged and with whom.

The patient should follow up with a urologist within 2-4 weeks for clinical re-evaluation.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

A CBC showing resolution of any leukocytosis should be performed. Urine cultures should also have appropriate speciation and susceptabilities listed by the time of discharge. For any infant or boy with epididymitis an abdominopelvic ultrasound should be performed to rule out congenital structural abnormalities.

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

Infants or boys with epididymitis should have an ultrasound and potentially a voiding cystourethrography performed prior to or on the day of their clinic visit.

E. Placement Considerations.

Patient may be discharged to his home or prior living arrangement. No special placement considerations are merited.

F. Prognosis and Patient Counseling.

Most patients with acute epididymitis recover fully with no residual effects. Chronic cases as mentioned are thought to be self-limiting but may take years to truly completely resolve.

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.


B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Any patient with epididymitis should be counseled to seek immediate medical attention if presented with similar symptoms in the future given the chance that they may have testicular torsion which if ignored can result in testicular loss. Patients should also be urged to complete their entire course of antibiotics even if they feel early improvements in their physical condition. Of note, all patients should be educated and reminded of safe sexual habits to reduce the chances of epididymitis secondary to a STD.

Notably, any young man who presents with an acute scrotum and has a scrotal ultrasound that reveals increased flow (evidence of hyperemia), torsion must be excluded (preferably by a urologist) as torsion – detorsion – retorsion can present in this way. In this scenario a patient can be discharged in the detorsed state and incorrectly treated for epidiymo-orchitis, only to suffer a re-torsion with organ loss.

VII. What's the evidence?

Nickel, JC, Wein. “Inflammatory Conditions of the Male Genitourinary Tract: Prostatitis and Related Conditions, Orchitis, Epididymitis”. Campbell-Walsh Urology,. 2007. pp. 304-329.

Weiss, JP, Kohn, IJ, Hanno, PM. “Urologic Emergencies”. Penn Clinical Manual of Urology,. 2007. pp. 259-282.

Wieder, JA, Wieder, JA. “Emergent Urologic Conditions”. Pocket Guide to Urology,. 2010. pp. 384-388.

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