• Epididymitis is an inflammatory reaction of the epididymis caused by either an infectious agent or local trauma. In most cases of acute epididymitis, the testis is also involved (orchitis).
• Epididymitis is considered chronic if lasting ≥6 wk. Chronic epididymitis has been subcategorized into inflammatory chronic epididymitis, obstructive chronic epididymitis, and chronic epididymalgia.

Nonspecific bacterial epididymitis

Sexually transmitted epididymitis

• Tender swelling of the scrotum with erythema, usually unilateral testicular pain and tenderness
• Dysuria and/or urethral discharge
• Fever and signs of systemic illness (less common)
• Pain and redness on scrotal examination
• Hydrocele or even epididymo-orchitis, especially late
• Chronic draining scrotal sinuses with a “bead-like” enlargement of the vas deferens in tuberculous disease

• In young, sexually active men (<35 yr of age), the most common causes of infections are Neisseria gonorrhoeae and Chlamydia trachomatis.
• In older men (>35 yr of age) or those with underlying urologic disease:
  1. Gram-negative aerobic rods are predominant (i.e., Escherichia coli).
  2. Similar organisms are found in men after invasive urologic procedures.
  3. Gram-positive cocci are rarely seen in these groups.
  4. Mycobacterium tuberculosis (TB) may also be a cause of epididymitis.
• Acute epididymitis caused by sexually transmitted enteric organisms (e.g., E. coli) also occurs among men who are the insertive partner during anal intercourse.
• Young, prepubertal boys may present with epididymitis caused by coliform bacteria; almost always a complication of underlying urologic disease such as reflux.
• In AIDS patients, cytomegalovirus (CMV) and Salmonella epididymitis have been described. CMV may have a negative urine culture. Toxoplasmosis and Cryptococcus should also be considered as a cause of epididymitis in AIDS patients.
• Chronic infectious epididymitis is most frequently seen in conditions associated with granulomatous reaction; TB is the most common granulomatous disease affecting the epididymis.

• Orchitis
• Testicular torsion, trauma, or tumor
• Epididymal cyst
• Hydrocele
• Varicocele
• Spermatocele
• Testicular torsion should be considered in all cases (Table E1)

• Consideration of a full assessment of the urologic tract in patients with bacterial infection, especially if recurrent.
• If discharge is present, cultures and Gram stain smear of urethral exudate. Gram stain should demonstrate ≥2 white blood cell (WBC) per oil immersion field.
• If testicular torsion a consideration: Radionuclear imaging.
• Examination of first-void uncentrifuged urine for leukocytes if the urethral Gram stain is negative. Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine sediment will demonstrate ≥2 WBC per high power field. A culture and Gram-stained smear of this urine specimen should be obtained along with nucleic acid amplification testing (NAAT) from urine samples for gonorrhea and chlamydia. Mycoplasma genitalium should also be considered. Rectal and oropharyngeal NAAT for gonorrhea and chlamydia may also be helpful in diagnosis if indicated.
• Imaging with sonogram (Fig. E1).

• All suspected cases of acute epididymitis should be tested for C. trachomatis and for N. gonorrhoeae by NAAT. Urine is the preferred specimen for NAAT testing.
• Urinalysis and urine culture if dysuria is present or if urinary tract infection is suspected.
• HIV testing and counseling.
• Purified protein derivative placed and chest x-ray viewed if TB suspected (rare cases).
• Rarely, biopsy to ensure the diagnosis of tuberculous epididymitis.

• Ice packs and scrotal elevation for relief of pain.
• Analgesia with acetaminophen with or without codeine or NSAIDs.
• Antibiotics to cover suspected pathogens. Empirical therapy is indicated before laboratory test results are available, but treatment should be guided by culture and susceptibility data.
• Recommended empirical regimens include ceftriaxone 500 mg (if <150 kg of body weight) OR 1 g (if ≥150 Kg of body weight) in a single dose plus doxycycline 100 mg bid for 7 days. For acute epididymitis most likely caused by enteric organisms, levofloxacin 500 mg/day × 10 days.
• Best treatment for older men with gram-negative bacteriuria: Levofloxacin 500 mg/day PO for 10 days.
• Pseudomonas treatment should be based on antimicrobial susceptibilities, but could be covered by ciprofloxacin PO or IV or cefepime (2 g IV q8h).
• Consider ampicillin-sulbactam, third-generation cephalosporin, ticarcillin-clavulanate, or piperacillin-tazobactam in toxic-appearing patients.
• Surgical aspiration of local abscesses or even open surgical drainage.
• Diabetics: Especially prone to develop more extensive scrotal infections, including Fournier gangrene.
• Reinforcement of compliance with antibiotics to avoid partial treatment.

• Repair of underlying structural defects is considered especially if infections are severe or recur.
• Surgical repair of reflux in young boys should be undertaken promptly and at a young age when possible.
• Sex partners of patient should be referred for evaluation and treatment.

• If abscess or chronic structural problems suspected
• If another diagnosis, such as testicular torsion, is suspected

Epididymitis (Patient Information)

Orchitis (Related Key Topic)

Testicular Torsion (Related Key Topic)