Epididymitis: Signs, Diagnosis, and Treatment

Epididymitis is an unwelcome problem and a significant cause of urologic issues. It is found in relatively young men but also adults. The age of onset is 18 years to 50 years.

This problem is caused by inflammation, and it has similar symptoms to certain testicular conditions.

The epididymis is a tubular structure in a spiral formation that we can locate in the back of the testis. The epididymis connects different ducts and joins them into the vas deferens. This is where sperm cells travel during ejaculation. The epididymis contributes to the maturation, storage, and transportation of sperm cells.

What is epididymitis?

Epididymitis is the inflammation of the epididymis, a structure described above. It is usually due to infection by bacterial agents. However, sometimes doctors obtain no sign of infection and active inflammation. Thus, other agents have been involved, including virus, trauma, and idiopathic epididymitis.

What we know as mumps orchitis is a common cause of epididymitis as well. The testicles should be evaluated in children with mumps because the virus has a preference for this structure and causes severe infections (1).

What causes it?

The exact causes of epididymitis are often unclear. A patient with a recently diagnosed epididymitis won’t be able to trace back its origin in most cases. Still, researchers have realized that a retrograde flow of urine can be one of the causes.

This urine is sterile in the bladder (unless there’s a urinary tract infection), but it reaches the urethra and drags microorganisms when it flows back. This reflux sometimes reaches the vas deferens, the ejaculatory ducts, and the epididymis. 

Patients with prostate enlargement due to benign prostatic hyperplasia or cancer are at a higher risk. They have a predisposition for urine reflux to the epididymis and infection of this tissue. That’s why more than half of men with epididymitis aged 60 years or older also have a type of bladder outlet obstruction. It is usually BPH, but it can also be a urethral stricture or prostate cancer (1).

This urinary reflux can reach further back with Valsalva maneuvers. So, if a patient has a reflux predisposition and practices strenuous exercise, the risk is even higher. This explains why epididymitis is not unusual in weight lifters and some athletes.

Another risk factor is using indwelling catheters because they often lead to urinary infections.

But let us break down epididymitis into acute and chronic to see how are their causes and risk factors different from the other:

Acute epididymitis

In this case, the infection is often severe, and the symptoms are more intense. In many cases, both testicles are taken because the condition is easily spread to the other testicle. The most common cause of acute epididymitis is urinary microorganisms, especially Escherichia coli, Klebsiella, and Proteus species in older adults and children. Men who practice anal intercourse may also develop epididymitis with coliform bacteria.

Sexually-transmitted epididymitis is a possibility, and it should be ruled out in any sexually active patient, especially if he’s around 35 years or less. Sexually-transmitted diseases cause approximately 50% of acute epididymitis cases, and the most common agents are Neisseria gonorrhea, Chlamydia tracomatis, Treponema pallidum, and Trichomonas.

Additionally, we need to talk about tuberculosis as a cause of acute epididymitis. It is common in endemic areas and spreads through the blood. Viral epididymitis is also common, but usually in pediatric patients with the mumps virus. But other viruses have the same affinity to the epididymis and the testicle. Varicella, Coxsackievirus A, and echovirus should all count as a possibility (2).

Finally, we can’t forget about idiopathic epididymitis. This is an auxiliary term used by doctors when they have no idea where it came from. They may have done all of the appropriate tests, and everything appears to be normal. These challenges to medical knowledge or understanding are known as idiopathic causes.

Chronic epididymitis

This is when epididymitis symptoms come and go, become refractory, or stay mild for a long while. These patients have recurrent cases of scrotal pain. In most cases, they went through inadequate treatment of their condition. 

But in some cases, chronic epididymitis is not merely a partially cured acute epididymitis. It could be an infection with Mycobacterium tuberculosis. This causes an inflammatory reaction with granuloma formation and swelling of the epididymis (1).

Symptoms to look out for

The symptoms and findings in the physical examination of a patient with epididymitis are usually the following (3):

• Scrotal pain: It is usually not a sudden pain. Instead, it is gradual and lingering. It can be unilateral (in only one testicle) or bilateral (in both testicles). The maximum severity of the pain starts bothering patients after a few days instead of hours in the case of testicular torsion. 
  
  
• Scrotal swelling: This is also important, and you can sometimes notice different signs of inflammation. They are an increase in volume, redness, and warmth. It is essential to differentiate swelling from hydrocele, which is edema or an accumulation of liquid in the scrotum.
  
  
• Urinary symptoms: Most urologic problems and male genital issues are associated with urinary symptoms. In this case, patients often report dysuria (pain or a burning sensation while urinating). They may also have an increased urinary frequency or urinary urgency.
  
  
• Fever and chills: These symptoms can be found in around 25% of adults. In the case of epididymitis in children, the chance is a bit higher (approximately 71%). It is a clear sign of an infection that should be traced to the urinary system due to urologic findings.
  
  
• Diarrhea and vomiting: You can find these symptoms. But it is infrequent. It is more common in cases of testicular torsion.
  
  
• Urethral discharge: In some cases, there is also an active sexually transmitted infection with urethral discharge. This symptom sometimes develops before the onset of epididymitis.

When a lot of time has passed, epididymitis can become a chronic issue. In chronic epididymitis, we can find symptoms such as (3):

• Chronic scrotal pain: It is a type of pain that comes and goes or remains constant and mild for a long time. It is usually around 6 weeks or more.
  
  
• Scrotal induration: In these cases, it is not common to actually see scrotal inflammation or swelling. However, the skin becomes indurated and changes its feel.

In patients with epididymitis, a diagnosis of mumps orchitis is prevalent comorbidity. In these cases, the symptoms include (4):

• Fever, myalgia, and malaise: This is probably one of the most important findings. Myalgia is different from epididymitis, and the patient feels somewhat weak and unwell (malaise).
  
  
• Swelling of the parotid gland: This is mumps, and it often precedes orchitis and epididymitis. In most patients, it takes 3 to 5 days to develop the symptoms. Older patients are at a higher risk.
  
  
• Subclinical infectious diseases: In the physical exam, the doctor may also find signs and symptoms that point to another infection besides epididymitis. In up to 40% of patients, multiple infectious agents are involved in the disease.

How is epididymitis diagnosed?

One of the most critical parts of the diagnosis in epididymitis is listening to the patient. Thus, be sure to tell your doctor everything you feel or started to feel in the past. This way, it will be possible to draw a complete sketch of what is probably going on. It also allows doctors to create an entire medical history that will contribute significantly to the diagnosis.

The next step to diagnose epididymitis is through physical examination. It is a fundamental step to distinguish between testicular torsion and epididymitis. Both of them have similar symptoms, but testicular torsion usually develops suddenly, and it is very severe. 

Your doctor will probably look for these signs in the physical evaluation (3,4):

• Induration of the skin and tenderness. As noted above, induration is a sign of chronic epididymitis. It is essential to assess tenderness to rule out testicular torsion. Induration and tenderness usually start in the epididymal tail and start spreading to higher structures.
  
  
• Changes in the position of the scrotum: We may see an elevation of the affected testicle or both testicles if they are both affected. This is a guarding mechanism, partly due to the pain but also caused by inflammation of the tissue.
  
  

• Redness of the scrotum: This is known as erythema, and it is a medical term for reddened skin due to an inflammatory process. Your doctor may even find mild cellulitis in the skin of the scrotum. Cellulitis is an infection of the underlying layers of the skin.
  
  
• Reactive hydrocele: In other words, liquid in the scrotum increases the size of the scrotal bags. This finding is not common in epididymitis unless it is an advanced case associated with orchitis.
  
  
• Painful prostatic massage: In the physical exam, your doctor may require to perform a digital rectal examination. This is to evaluate your prostate gland for signs of prostatitis. Bacterial prostatitis is a common finding in epididymitis patients.
  
  
• Anomalies of the urogenital tract: In some cases, we can also find an abnormal urinary tract structure that contributes to the infection.

After considering your medical records and a complete physical exam, doctors proceed with the diagnosis with laboratory studies to confirm epididymitis. The exams may include (3,4):

• Urinalysis: It is perhaps one of the most important exams. It measures how many and what type of microorganisms can be found in your urine. Around half of infected patients may have pyuria or bacteriuria. This is pus or a very high count of microbes in the urine, respectively.
  
  
• Urine culture: It is imperative in elderly patients and prepubertal boys. It may also be useful in epididymitis that does not respond well to medical treatment.
  
  
• Complete Blood Count: It is a reliable way to verify that there is an active infection. This also shows the type of white blood cells attacking the agent. It gives us clues as to what type of microorganism is causing damage, either bacterial or viral.
  
  
• Urethral discharge examination: A sample of the urethral discharge is taken and prepared with Gram stain. Under the microscope, the doctor will identify the microorganism that is causing the problem.
  
  
• Urethral culture: A swab is taken inside of the urethra to get a sample of urethral mucosa and analyze it in a lab. They run nucleic acid amplification and hybridization tests to rule out Chlamydia trachomatis and Neisseria gonorrhoeae.
  
  
• HIV and syphilis tests: These patients can be coinfected with either HIV, syphilis, or both.
  
  
• C reactive Protein and Erythrocyte Sedimentation Rate tests: These tests provide an overall measure of inflammation. They differentiate epididymitis from other causes of acute scrotal pain.

In some cases, doctors can find it difficult to detect bacteria, even with advanced cultures. Still, epididymitis is usually an infectious process, and other imaging studies may be recommended, including (3,4):

• A pelvic, abdominal, or scrotal ultrasound to measure the size and subclinical edema
  
  
• Retrograde urethrography to see real-time what is happening inside of the urethra
  
  
• A voiding cystourethrogram to figure out how fluid is moving in the urinary tract.
  
  
• Radionuclide scanning, scintigraphy, chest radiography, and others

Treatment options

There are three branches of therapy for patients with epididymitis. They include medical (pharmacologic) treatment, supportive treatment, and surgery.

Pharmacologic treatment

Epididymitis is typically caused by an infectious agent causing damage and inflammation in the epididymis. It can be acute or chronic, and the pharmacologic treatment changes a bit depending on each case. 

In chronic epididymitis, antibiotic therapy should last for a longer time. In some cases, it is up to 6 weeks or more. Before starting treatment, your doctor would probably try to investigate the type of bacteria you have. If you have a sexually-transmitted disease giving you epididymitis, your sexual partners will also require medical treatment. Otherwise, you could get reinfected (1,5).

Children who have not reached puberty get special treatment because not all of them will receive antibiotic therapy. The pediatrician may order a urinalysis to determine if there is a positive urine culture or pyuria. Antibiotics will be administered if that is the case (6).

Supportive therapy

Antibiotics are only a small part of therapy, and we also have supportive treatment. This type of therapy is more like recommendations for patients to relieve their symptoms. They will not cure the disease but help us handle the problem while antibiotics do their job.

One of the most important recommendations is reducing physical activity and stopping all types of strenuous exercise. You might be recommended to sit or lay in bed differently, with a device or different means for scrotal support and with your pelvis slightly elevated. This allows the blood flow to return to your heart instead of causing edema.

Another recommendation is using ice packs, which cause blood vessel constriction. A reduction of blood relieves inflammation. Anti-inflammatory medications and analgesics can help a lot to relieve the pain. In most cases, over-the-counter options are enough for you.

You could also find relief by using a sitz bath, a shallow bath comfortable for your perineal area and scrotum. This device is designed to cleanse and provide relief to the perineal and scrotal areas.

Surgical treatment

Surgical options are only recommended in very advanced cases or when other treatments have failed. We can use (1,5,7):

• Epididymotomy: It is a surgical incision made to the epididymis. This is sometimes a preceding step for epi-didymo vasotomy. In other cases, epididymotomy can be used to drain pus from the epididymis.
  
  
• Epididymectomy: It is a complete remotion of the epididymis that is infected by inflammation. It is more complicated but also an outpatient surgery. In other words, you can go back home after surgery.
  
  
• Orchiectomy: It is the complete remotion of the epididymis and the affected testicle. This is a suitable option when the infection and inflammation are not restricted to the epididymis. When it has taken the testicles, orchiectomy can be considered. It is beneficial if the patient has unrelenting pain associated with the disease.
  
  
• Skeletonization of the spermatic cord: This procedure is performed very rarely and only in patients with refractory pain. They usually have chronic epididymitis that has not responded to any other treatment.

Outlook

When patients start taking their treatment, their scrotal pain improves after 1-3 days. However, the skin may still look indurated or a bit reddened. Sterility is a possibility, but not the most frequent. It is only considered when the disease takes both testicles.

It is also important to let patients know that if they acquired epididymitis with a sexually transmitted disease, the risk of developing HIV is 2-5 times higher than the rest of the population.

In most cases, patients with epididymitis respond to antibiotic therapy. They are not particularly difficult to handle. However, even with the most skilled doctor, some patients may develop complications. First of all, most complications start arising when epididymitis is associated with bacterial orchitis. In other words, when it is not only the epididymis that is infected but the testicle as well. These patients can develop additional problems. For example:

• The development of a scrotal abscess or a pyocele (similar to hydrocele but with a collection of pus in the scrotal sac)
  
  
• Testicular infarction in cases of very severe infection. Swelling does not stay in the testicles but also goes up to the spermatic cord. This increases the volume of the cord and pushes away arteries, compromising blood flow. In the end, this leads to infarction of the affected testicle.
  
  
• Fertility problems, especially in patients who undergo complications listed above. Still, sterility is not common after epididymitis. The inflammation and leukocytes can affect sperm quality momentarily. However, all of these effects are transient.
  
  
• Testicular atrophy because prolonged inflammation replaces the normal tissue. It starts as a secretory tissue and turns into more fibrous and less functional tissue.
  
  
• Fistula formation, which is a common problem in cases of prolonged inflammation. This is a tiny canal that connects two organs together. It is more common in cases of tuberculosis.
  
  
• Recurrence of the symptoms, especially in cases of chronic epididymitis. This disease is sometimes difficult to handle, and some patients experience episodic flare-ups.

Moreover, if your epididymitis is associated with mump orchitis, you should be careful with these complications:

• Hypogonadotropic hypogonadism. In other words, a failure in your testicles to create testosterone and possibly sperm. These patients can have testicular atrophy in up to 50% of cases.
  
  
• Sterility is not very common, but it happens to 13% of patients with mumps orchitis. Even if they are not sterile, their sperm count, morphology, and other features can be affected.

Conclusion

Bacterial infection and viral infection in the epididymis are common causes of epididymitis. It is an inflammatory process that features testicular pain and leading to acute scrotum symptoms or chronic disease. 

Bacterial epididymitis is usually caused by an enteric organism such as Escherichia coli. However, a sexually transmitted disease can also reach this structure. In immunocompromised patients, tuberculous epididymitis and other possible infections may be associated with testicular pain. And patients with an enlarged prostate have a slightly higher risk of this type of condition.

Most patients with epididymitis improve in 2-3 days with antibiotic therapy. However, they need to continue taking their antibiotics to achieve a complete resolution of the problem. Otherwise, it could turn into chronic epididymitis. Along with antibiotics, patients will be recommended anti-inflammatories and other medications to control their symptoms.

When nothing else works or epididymitis is very severe and starting to invade other tissues, surgical procedures are recommended to take out the affected region. Prognosis is usually excellent, and most complications develop in patients who neglect their condition.

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