Epididymitis
Basics
Description
- Inflammation (infectious or noninfectious) of the epididymis resulting in scrotal pain and swelling, induration of the posterior epididymis, involvement of the adjacent testicle, and possible hydrocele formation
- Acute epididymitis: scrotal pain for <6 weeks
- Chronic epididymitis: scrotal pain for ≥6 weeks
- Epididymitis with involvement of the testis is named epididymo-orchitis.
- Classification: infectious (bacterial, viral, fungal, parasitic) versus noninfectious (chemical, traumatic, autoimmune, idiopathic, industrial, vaso-epididymal reflux syndrome)
- System(s) affected: reproductive
Epidemiology
- Predominant age: generally younger, sexually active men or older men with UTIs and bladder outlet obstruction (e.g., benign prostatic hyperplasia [BPH])
- Predominant sex: male only
Pediatric Considerations
Epididymitis is found to be the most common cause of acute scrotal pain in prepubertal boys—more common than testicular torsion.
Incidence
- Common (600,000 cases annually in the United States) (1)
- 1 in 1,000 adult males per year
- 1.2 in 1,000 boys aged 2 to 13 years per year (2),(3)
Prevalence
Common
Etiology and Pathophysiology
- Infectious epididymitis
- Retrograde passage of 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.
- Noninfectious epididymitis
- Often, no etiology is found; however, can be instigated by trauma, autoimmune disease, or vasculitis
- Likely secondary to reflux of sterile urine causing a chemical inflammation
- Can develop as sequelae of strenuous exercise with a full bladder when urine is pushed through internal urethral sphincter (located at proximal end of prostatic urethra) or prolonged periods of sitting
- Reflux of urine through orifice of ejaculatory ducts at verumontanum may occur with history of urethritis/prostatitis because 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.
- <14 years of age
- Cause largely unknown, although likely from anatomic abnormalities resulting in urine reflux such as vesicoureteral reflux, ectopic ureter, or anorectal malformation (rectourethral fistula)
- May also result from postinfectious syndrome from Mycoplasma pneumoniae, enterovirus, or adenovirus
- Henoch-Schönlein purpura may present as acute scrotal pain.
- 14 to 35 years of age
- Usually Chlamydia trachomatis, Neisseria gonorrhoeae, or Mycoplasma genitalium in sexually active males
- With anal intercourse, likely enteric pathogens (e.g., Escherichia coli)
- >35 years
- Commonly enteric bacteria but occasionally Staphylococcus aureus or Staphylococcus epidermidis
- In elderly men, often with distal urinary tract obstruction, 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.
- Sterile urine reflux after transurethral prostatectomy
- Granulomatous reaction following BCG intravesical therapy for bladder cancer
- Amiodarone may cause a dose-dependent noninfectious epididymitis; usually resolves with decreasing drug dosage (<200 mg/day)
- 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 (BPH, prostate cancer)
- HIV-immunosuppressed patient
- Severe Behçet disease
- Presence of foreskin
- Constipation
- 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
- Safer sexual practices
- Mumps vaccination
- Antibiotic prophylaxis for urethral manipulation
- Early treatment of prostatitis/BPH
- Vasectomy or vasoligation during transurethral surgery
- 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
- Hematospermia
- Constipation
- UTI
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Citation
Domino, Frank J., et al., editors. "Epididymitis." 5-Minute Clinical Consult, 33rd ed., Wolters Kluwer, 2025. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis.
Epididymitis. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2025. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis. Accessed November 5, 2024.
Epididymitis. (2025). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (33rd ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis
Epididymitis [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2025. [cited 2024 November 05]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116211/all/Epididymitis.
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