Epididymitis: Symptoms, Types, Causes and Treatment

Epididymitis is a common but often misunderstood condition characterized by inflammation of the epididymis—a coiled tube at the back of the testicle that stores and carries sperm. Affecting males of all ages, it can cause significant discomfort and, if left untreated, may lead to complications such as infertility or chronic pain. Understanding the symptoms, types, underlying causes, and available treatments can make a significant difference in patient outcomes and quality of life.

Symptoms of Epididymitis

Recognizing the symptoms of epididymitis is crucial for early diagnosis and effective treatment. The way the condition presents can vary depending on whether it is acute or chronic, the age of the patient, and the underlying cause. Most commonly, men notice a gradual onset of pain and swelling in one side of the scrotum, but a range of other symptoms may occur.

Symptom	Description	Duration	Source(s)
Scrotal Pain	Gradual onset, often unilateral	Acute: days; Chronic: ≥3 months	2 3 4 5 7
Swelling	Tender, enlarged epididymis	Usually acute	2 3 4 5 6
Urinary Issues	Dysuria, frequency, urgency	Variable	2 4 5
Systemic Signs	Fever, malaise (sometimes)	Often acute	2 4 5 8
Urethral Discharge	Especially with STIs	Acute	5 9 15
Chronic Pain	Persistent, often without swelling	≥3 months	1 7 8
Quality of Life Impact	Discomfort affecting daily activities	Chronic	1

Table 1: Key Symptoms

Gradual Onset and Pain

• Scrotal pain is the hallmark symptom, usually developing gradually over a few days. The pain is typically localized to one side and can range from mild discomfort to severe, incapacitating pain 2 3 4.
• In chronic cases, pain persists for at least three months and may fluctuate in intensity 1 7.

Swelling and Tenderness

• The epididymis becomes swollen and tender, which can be detected during a physical exam. Swelling may be accompanied by redness and warmth 2 4 5 6.
• In acute cases, the pain and swelling are often pronounced, whereas in chronic forms, swelling is less common 1 7.

Urinary and Systemic Symptoms

• Many patients also experience urinary symptoms, such as burning during urination (dysuria), increased frequency, and urgency. These are more common when the infection involves urinary tract pathogens 2 4 5.
• Fever and malaise are sometimes present, especially in acute bacterial epididymitis 2 4 5 8.

Urethral Discharge and Sexual History

• In sexually active men, especially those under 35, urethral discharge may occur, which is a sign of sexually transmitted infection (STI) 5 9 15.
• A recent history of sexual contact can be a clue, particularly in younger men presenting with severe pain and tenderness 5.

Chronic Symptoms and Quality of Life

• Chronic epididymitis is marked by long-lasting pain (≥3 months), often without swelling. Patients may experience significant impacts on their quality of life, including discomfort during daily activities and sexual dysfunction 1 7 8.

Types of Epididymitis

Epididymitis is not a one-size-fits-all diagnosis. It can be classified in several ways, primarily based on the duration and underlying cause. Understanding the types helps tailor the approach to management and prognosis.

Type	Key Features	Typical Duration	Source(s)
Acute	Sudden, severe pain/swelling	<6 weeks	3 4 7 8
Chronic	Persistent/discomfort, less swelling	≥3 months	1 7 8
Inflammatory	Non-infectious, immune-mediated	Variable	1 7 10
Obstructive	Due to duct blockage	Often chronic	1 12
Epididymalgia	Pain without clear inflammation	Chronic	1

Table 2: Types of Epididymitis

Acute Epididymitis

• Acute epididymitis manifests rapidly, usually with severe pain and swelling in one testicle. Symptoms develop over a few days, often accompanied by fever and urinary complaints 3 4 7 8.
• It is most often caused by infection and responds well to prompt antibiotic therapy 2 4.

Chronic Epididymitis

• Chronic epididymitis is defined by pain lasting three months or longer, with or without swelling. The symptoms can wax and wane, and the cause is frequently elusive 1 7 8.
• Chronic cases often impact quality of life and sometimes resist standard therapies 1.

Inflammatory, Obstructive, and Epididymalgia Subtypes

• Recent research proposes a further classification:
  • Inflammatory: Characterized by persistent inflammation, sometimes due to autoimmune mechanisms or post-infectious changes 1 7 10.
  • Obstructive: Results from blockage of the epididymal duct, often due to fibrosis after infection (notably with E. coli), leading to impaired sperm transport 1 12.
  • Epididymalgia: Chronic pain localized to the epididymis without obvious signs of inflammation or infection 1.

Causes of Epididymitis

Understanding what triggers epididymitis is essential for both prevention and effective treatment. The causes vary by age, sexual activity, and sometimes underlying health conditions.

Cause	Patient Group	Pathogen/Trigger	Source(s)
Sexually Transmitted	Males 14–35, sexually active	Chlamydia trachomatis, Neisseria gonorrhoeae	2 4 6 9 15 16
Urinary Tract Pathogens	Older men, children, anatomical abnormalities	Escherichia coli, coliforms	2 4 6 9 11 12 15 16
Non-infectious	Any age, often chronic	Trauma, autoimmune, drugs, urinary reflux	1 7 10 14
Viral	Children, post-infectious	Mumps, enteroviruses, adenoviruses	6 10 14
Idiopathic	Any group	Unknown	1 7 11

Table 3: Common Causes of Epididymitis

Sexually Transmitted Infections (STIs)

• In men aged 14–35, Chlamydia trachomatis and Neisseria gonorrhoeae are the leading causes. These bacteria ascend the urogenital tract following sexual contact 2 4 6 9 15 16.
• STIs are less common in older men and children, but they should always be considered in sexually active individuals presenting with symptoms 11.

Urinary Tract and Enteric Pathogens

• Coliform bacteria, especially Escherichia coli, are the main culprits in older men, young boys, and those with structural abnormalities or urinary tract obstruction 2 4 6 9 11 12 15 16.
• Retrograde flow of urine into the ejaculatory ducts is a significant mechanism, especially in children and men with bladder outlet obstruction 4 6.

Non-infectious Causes

• Non-infectious epididymitis arises from:
  • Trauma (e.g., injury or surgery)
  • Autoimmune reactions (body’s immune system attacking self-tissues)
  • Medications (such as amiodarone)
  • Urinary reflux, particularly in children 1 7 10 14
• These cases are more likely to result in chronic symptoms.

Viral and Post-infectious Etiologies

• Viral infections (notably mumps, enteroviruses, adenoviruses) can cause epididymitis, especially in children. These are often self-limited and may represent post-infectious inflammation rather than direct infection 6 10 14.

Idiopathic Cases

• In many cases—especially chronic ones—the exact cause remains unknown, and these are termed idiopathic 1 7 11.

Treatment of Epididymitis

Management of epididymitis hinges on identifying and addressing the underlying cause. Prompt treatment can alleviate symptoms, prevent complications, and improve quality of life.

Approach	Description	Indication	Source(s)
Antibiotics	Empirical, then targeted therapy	Acute, bacterial cases	2 4 7 11 15 16
Analgesics/NSAIDs	Pain relief, anti-inflammatory	All cases	1 4 7 8 14
Supportive Care	Scrotal elevation, rest, ice	Symptom control	4 7 8 14
STI Partner Treatment	Screen and treat sexual partners	STI-related cases	15
Surgery	Epididymectomy, cord block	Severe, chronic, refractory	1 7 8
Address Risk Factors	Treat underlying urinary obstruction, stop causative drugs	As appropriate	4 7 10 12

Table 4: Treatment Strategies

Antibiotic Therapy

• Empirical antibiotics are started immediately, tailored to the likely pathogens and patient’s age:
  • Sexually active men (14–35): Ceftriaxone (single IM dose) plus doxycycline (10 days) 2 4 7.
  • Enteric/urinary pathogens (older men, children): Levofloxacin or ofloxacin 2 4 7 11 16.
• Adjustments are made once culture results are available.

Pain Management & Supportive Measures

• Analgesics and NSAIDs (non-steroidal anti-inflammatory drugs) help relieve pain and reduce inflammation in both acute and chronic cases 1 4 7 8 14.
• Supportive care includes bed rest, scrotal elevation, and applying ice packs to reduce swelling and discomfort 4 7 8 14.

Treating Sexual Partners

• When STIs are identified as the cause, sexual partners must also be examined and treated to prevent reinfection 15.

Addressing Underlying Issues

• For recurrent or chronic cases, it’s essential to treat underlying risk factors, such as bladder outlet obstruction or discontinuing causative medications 4 7 10 12.
• Non-infectious chronic epididymitis may respond to anti-inflammatory medications, nerve blocks, or (rarely) surgical interventions such as epididymectomy or spermatic cord microdenervation 1 7 8.

Surgery

• Surgical treatments are reserved for severe, refractory cases, especially chronic epididymitis that does not respond to medical management 1 7 8.
• Surgery may involve removal of the epididymis (epididymectomy) or procedures to block pain transmission 1 7.

Special Considerations

• Children often recover with supportive care alone, as most cases are post-infectious and self-limited 14.
• Fibrosis and infertility risk: Some infections (notably E. coli) can cause fibrosis of the epididymis, leading to obstruction and potential infertility, highlighting the need for early and effective treatment 12 13.

Conclusion

Epididymitis is a multifaceted condition that can impact men and boys across all ages. Prompt recognition and tailored treatment are essential to prevent complications and improve outcomes.

Key Takeaways:

• Epididymitis commonly presents with gradual onset pain, swelling, and sometimes urinary or systemic symptoms.
• It can be classified as acute or chronic, with subtypes based on cause and presentation.
• Causes vary by age and sexual activity: STIs in younger, sexually active men; urinary pathogens in older men and children; non-infectious or idiopathic in many chronic cases.
• Treatment is cause-specific: antibiotics for bacterial cases, supportive care for viral or post-infectious cases, and surgical options for refractory chronic disease.
• Early diagnosis and appropriate management are crucial to avoid chronic pain and infertility.

Understanding these aspects empowers patients and clinicians to work together towards effective management and improved quality of life.