What Is Epididymitis?

Epididymitis is the inflammation of the epididymis, the coiled tube at the back of the testicle that stores and carries sperm. Epididymitis is recognized by pain, redness, and swelling, usually in one testicle only. Bacterial infections are the predominant cause of epididymitis, especially sexually transmitted infections like chlamydia and gonorrhea. Epididymitis is diagnosed based on a review of symptoms along with blood tests and bacterial cultures to identify the underlying cause. The mainstay of treatment are antibiotics based on the bacteria involved.

Doctor using digital tablet with patient
Getty Images/Ariel Skelley

Types of Epididymitis

Epididymitis can be characterized by the duration of the inflammation as well as the speed of the onset of symptoms. Both of these things can suggest what the underlying cause of epididymal swelling is.

Acute epididymitis is characterized by the rapid onset of symptoms and, by definition, lasts for no more than six weeks. It is almost always related to some sort of infection, often one that is sexually trasmitted.

Epididymitis is considered chronic if it persists for over 12 weeks (and in excess of five years in some cases). It's less common and manifests with recurrent episodes of pain, inflammation, and swelling. The cause of chronic epididymitis can be hard to pin down but may be related to a past injury, surgery, or infection that damaged the epididymis is some way.

Symptoms

Symptoms of epididymitis can vary by whether the condition is acute or chronic. Generally speaking, acute epididymitis pain tends to be sharp while chronic epididymitis causes dull or throbbing pain.

Common Symptoms

Men with acute and chronic epididymitis may experience some or all of the following signs and symptom:

  • Pain and pressure in the testicle (usually one)
  • Redness, warmth, and swelling of the scrotum
  • Pain during urination
  • The need to urinate often
  • Pain during sexual intercourse or ejaculation
  • Blood in semen

Acute Epididymitis

Acute epididymitis tends to develop over several days with the pain, redness, swelling, and warmth typically limited to one testicle. The scrotum of the affected testicle will often hang lower.

The epididymis itself will feel significantly thicker and firm. There may be a visible discharge from the opening of the penis (urethra) and pain or burning when urinating. 

Fever, chills, penile discharge, and swollen lymph nodes in the groin are all signs of a urinary tract infection.

Chronic Epididymitis

Chronic epididymitis may manifest with persistent tenderness and discomfort, although the actual swelling of the epididymis can come and go. The pain will often radiate to the groin, thigh, and lower back. Sitting for prolonged periods can make it worse.

The persistent inflammation associated with chronic epididymitis can "spill over" to the prostate, leading to discomfort in the groin and perineum (the area between the scrotum and anus) as well as difficulty urinating.

Complications

If left untreated, acute epididymitis can lead to major complications, including the development of testicular abscesses and necrosis (tissue death). Chronic epididymitis may cause permanent obstruction of the epididymis, leading to reduced fertility and hypogonadism (low testosterone levels).

In some cases, the underlying infection can spread to other organs. Men with benign prostatic hyperplasia (enlarged prostate) may experience a worsening of symptoms as the result of epididymal inflammation.

Causes

Epididymitis is not a disease but rather the consequence of a disease. Though epididymitis is commonly associated with bacterial infections, there are non-infectious causes that can affect both men and boys. Boys and men ages 14 to 35 are most often affected.

Infectious Causes

Though urinary tract infections (UTIs) are rare in men, bacterial infections are the most common cause of acute epididymitis. These include:

  • Sexually transmitted bacterial infections like chlamydia (Chlamydia trachomatis) and gonorrhea (Neisseria gonorrhoeae)
  • Escherichia coli (E. coli), a bacteria that can invade the urethra through fecal contamination or anal sex
  • Complications of tuberculosis (TB)
  • Viral infections like enterovirus, adenovirus, and influenza in younger boys
  • Opportunistic infections like ureaplasma, mycobacterium, cytomegalovirus, or cryptococcus in men with HIV

Men who engage in unprotected sex and/or are circumcised are at greater risk of epididymitis overall.

Some men with chronic epididymitis will have had a previous acute infection that has damaged the epididymis. In some cases, the injury may affect blood vessels or nerves that service the epididymis, making it vulnerable to bouts of inflammation during illness, extreme physical activity, or other possible triggers.

Non-Infectious Causes

There are also non-infectious causes of epididymitis. These include:

  • Benign prostatic hypertrophy (an enlarged prostate)
  • Genitourinary surgery (including vasectomy)
  • Urinary reflux (the backflow of urine)
  • Urinary catheters
  • Corarone (amiodarone), a drug used to treat heart rhythm disorders that is also available as Pacerone
  • Sarcoidosis, a disease characterized by hardened granulomas
  • Behçet's disease, an autoimmune disorder that often causes epididymitis is black men

In younger boys, direct trauma and testicular torsion (the abnormal twisting of the testicle and epididymis) are the most common causes of epididymitis. The same can occur in adult men, often during sports or extreme physical activity.

Diagnosis

Epididymitis can be diagnosed with a review of symptoms and medical history. The physical exam would look for signs of redness, swelling, tenderness, and warmth occurring unilaterally (on one side only).

The doctor may also check for signs of discharge, often revealed by gentle milking the penis with gloved hands. If chlamydia or gonorrhea is suspected, the doctor will take a swab of the discharge and send it to the lab for evaluation. Blood and urine tests may be ordered to identify other causes.

If the cause of the epididymitis is unclear or the symptoms are unusual, the doctor may order a Doppler ultrasound to visualize the epididymis and evaluate blood flow to the affected area.

Differential Diagnoses

Conditions that mimic epididymitis include inguinal hernia, infected hydroceles, and testicular cancer and so in order to be certain about the diagnosis and the most effective treatment, a doctor may want to exclude these and other possible causes.

To differentiate epididymitis from testicular torsion, the doctor may test the cremasteric reflex (in which the testicle rises when the inner thigh is stroked). A positive cremasteric reflex generally excludes testicular torsion as a cause. There would also be a positive Prehn sign, in which pain persists even when the scrotum is lifted.

A Doppler ultrasound is the most effective way to differentiate epididymitis from an inguinal hernia, hydroceles, and testicular cancer.

Treatment

The prompt treatment of epididymitis is essential to resolving the underlying infection, avoiding testicular damage, and preventing the transmission of a sexually transmitted disease.

Both acute and chronic epididymitis are treated with antibiotics. Azithromycin, ceftriaxone, and doxycycline are the antibiotics of choice for chlamydia and gonorrhea. Cefixime, erythromycin, levofloxacin, or ofloxacin can be used as alternatives or to treat other types of infection.

The choice of antibiotic can vary based on the underlying cause and whether the condition is acute or chronic:

  • Chlamydia may be treated with a single 1-gram (g) dose of azithromycin or a daily 100-milligram (mg) dose of doxycycline for up to seven days.
  • Gonorrhea may be treated with a single 250-mg intramuscular injection of ceftriaxone or a single 1-g oral dose of azithromycin.
  • E. coli infections can be treated with a seven- to 14-day course of oral levofloxacin or ofloxacin.
  • Chronic epididymitis may require a four- to six-week course of azithromycin or ceftriaxone to ensure clearance of the infection.
  • Epididymitis in children caused by a UTI is best treated with co-trimoxazole or penicillin.

If you're prescribed an antibiotic for acute epididymitis you should begin to feel relief within 48 to 72 hours. Relief from chronic epididymitis will likely take longer.

It's vital to complete an entire course of antibiotics even if symptoms have resolved. If antibiotics are stopped too early there is a risk of antibiotic resistance, making it more difficult to treat a repeat bacterial infection.

Coping

Whether you have acute or chronic epididymitis, there are several simple things you can do to alleviate the discomfort of pain:

  • Rest with your feet elevated to take pressure off the scrotum.
  • Wear loose-fitting, non-constrictive underwear and pants or shorts.
  • Wear an athletic supporter to support the scrotum.
  • Avoid lifting heavy objects.
  • Take warms baths to increase blood flow to the scrotum, which will ease discomfort and aid healing.
  • Apply ice packs to reduce acute swelling, using a towel barrier and icing for no more than 15 minutes to prevent frostbite.
  • Take an over-the-counter analgesic like Tylenol (acetaminophen) or a nonsteroidal anti-inflammatory drug like Advil (ibuprofen) or Aleve (naproxen).

A Word From Verywell

If you develop epididymitis as a result of a sexually transmitted infection such as gonorrhea or chlamydia, it is important to inform your sexual partners so they can seek treatment. If you have had sexual contact within 60 days of the appearance of symptoms, then you are likely to have passed the infection to others. To avoid further transmission, avoid having sex until the infection is confirmed cured.

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