Epididymitis is a topic covered in the 5-Minute Clinical Consult.

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  • Acute epididymitis: pain for <6 weeks
  • Chronic epididymitis: pain for ≥3 months


  • Inflammation (infectious or noninfectious) of epididymis resulting in scrotal pain and swelling, induration of the posterior epididymis, and eventual scrotal wall edema, involvement of the adjacent testicle, and hydrocele formation.
  • Epididymitis with involvement of testis is named epididymo-orchitis
  • Classification: infectious (bacterial, viral, fungal, parasitic) versus sterile (chemical, traumatic, autoimmune, idiopathic, industrial, noninfectious, vasoepididymal reflux syndrome, vasal reflux syndrome); chronic versus acute
  • System(s) affected: reproductive


  • Predominant age: usually younger, sexually active men or older men with UTIs; in older men, usually secondary to bladder outlet obstruction
  • Predominant sex: male only

Pediatric Considerations
In prepubertal boys: Epididymitis is found to be the most common cause of acute scrotum—more common than testicular torsion.

  • Common (600,000 cases annually in the United States) (1)
  • 1 in 1,000 males per year


Etiology and Pathophysiology

  • Infectious epididymitis
    • Retrograde passage of urine or urinary bacteria from the prostate or urethra to the epididymis via the ejaculatory ducts and the vas deferens; rarely, hematogenous spread
    • Causative organism is identified in 80% of patients and varies according to patient age.
  • Sterile epididymitis
    • Chemical epididymitis occurs when sterile urine flows backward from the urethra to the epididymis
    • Can develop as a sequelae of strenuous exercise with a full bladder when urine is pushed through internal urethral sphincter (located at proximal end of prostatic urethra)
    • Reflux of urine through orifice of ejaculatory ducts at verumontanum may occur with history of urethritis/prostatitis, as inflammation may produce rigidity in musculature surrounding orifice to ejaculatory ducts, holding them open.
    • Exposure of epididymis to foreign fluid may produce inflammatory reaction within 24 hours.
  • <35 years and sexually active
    • Usually Chlamydia trachomatis or Neisseria gonorrhoeae
    • Look for serous urethral discharge (chlamydia) or purulent discharge (gonorrhea)
    • With anal intercourse, likely Escherichia coli or Haemophilus influenzae
  • >35 years
    • Coliform bacteria usually, but sometimes Staphylococcus aureus or Staphylococcus epidermidis
    • In elderly men, often with distal urinary tract obstruction, benign prostatic hyperplasia (BPH), UTI, or catheterization
    • Tuberculosis (TB), if sterile pyuria, nodularity of vas deferens (hematogenous spread), and recent infection. TB is the most common granulomatous disease affecting the epididymitis (2).
    • Sterile urine reflux after transurethral prostatectomy
    • Granulomatous reaction following BCG intravesical therapy for bladder cancer
  • Prepubertal boys
    • Usually coliform bacteria
    • Evaluate for underlying congenital abnormalities, such as vesicoureteral reflux, ectopic ureter, or anorectal malformation (rectourethral fistula).
  • Amiodarone may cause noninfectious epididymitis; resolves with decreasing drug dosage.
  • Syphilis, blastomycosis, coccidioidomycosis, and cryptococcosis are rare causes, but brucellosis can be a common cause in endemic areas.

Risk Factors

  • UTI
  • Prostatitis
  • Indwelling urethral catheter
  • Urethral instrumentation or transurethral surgery
  • Urethral or meatal stricture
  • Transrectal prostate biopsy
  • Prostate brachytherapy (seeds) for prostate cancer
  • Anal intercourse
  • High-risk sexual activity
  • Strenuous physical activity
  • Prolonged sedentary periods
  • Bladder obstruction (benign prostatic hyperplasia, prostate cancer)
  • HIV-immunosuppressed patient
  • Severe Behçet disease
  • Presence of foreskin
  • Constipation
  • Sterile epididymitis
    • Increased intra-abdominal pressure (due to frequent physical strain)
      • Military recruits, especially who begin physically unprepared.
      • Laborers; restaurant kitchen workers
      • Full bladder during intense physical exertion

General Prevention

  • Vasectomy or vasoligation during transurethral surgery
  • Safer sexual practices
  • Mumps vaccination
  • Antibiotic prophylaxis for urethral manipulation
  • Early treatment of prostatitis/BPH
  • Avoid vigorous rectal exam with acute prostatitis.
  • Emptying the bladder prior to physical exertion
  • Physically conditioning the body prior to engaging in regular intense physical exertion
  • Treat constipation.

Commonly Associated Conditions

  • Prostatitis/urethritis/orchitis
  • Hemospermia
  • Constipation
  • UTI

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