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Epididymo-orchitis:
diagnosis and management
RONO MUKHERJEE AND ANDREW M. SINCLAIR

The authors discuss the causes, differential

diagnosis and management of this painful
inflammatory condition.
pididymitis is an inflammatory condition
of the epididymis, which can also
involve the testis (epididymo-orchitis).1
This manifests itself clinically as acute
hemiscrotal pain and swelling (Figure 1),
usually secondary to bacterial infection,
but it may have non-infectious causes,
particularly in children (Box 1).
Alternatively, it may present as a chronic
painful relapsing/remitting condition.

CAUSES OF EPIDIDYMO-ORCHITIS
The majority of cases are of bacterial origin
(Gram-negative coliforms, particularly
Escherichia coli), arising from urinary bladder,
prostate or urethra and then refluxing via the
ejaculatory ducts and vasa deferentia into
the epididymis. The inflammatory response
usually commences in the tail of the
epididymis as it has the greatest blood
supply, before spreading to the body, head
and testis. Obvious risk factors include
urinary tract infection, bacterial prostatitis,
an underlying congenital abnormality (in
children), instrumentation/catheterisation,
and urinary stasis as a result of bladder
outlet obstruction.1
In sexually active men, particularly under
the age of 35 years, sexually transmitted
infections are the most common cause
(46 per cent if under 35 versus 7 per cent
if over 35), with Chlamydia trachomatis
and Neisseria gonorrhoea the obvious
pathogens.2 Infection may have occurred
months previously.
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DECEMBER 2010

Figure 1. Inflamed testicles in epididymo-orchitis (Dr P. Marazzi/

Science Photo Library)

In addition, mumps orchitis is on the rise,

as a result of the decline in vaccinations
over the past few years.35 Around 20-30
per cent of infected postpubertal males
suffer from this complication as a result of
haematogenous spread, generally 411
days after the onset of parotitis.5 The viral
infection then spreads to the epididymis,
and in 1030 per cent, bilateral orchitis
occurs. Severe infection may result in
testicular atrophy, presenting up to a year
later, and infertility (if mumps orchialgia is
bilateral). Antibiotic therapy should be
given, as a bacterial cause may not be
entirely ruled out and to reduce the risk
of secondary bacterial infection (even
with an obvious clinical diagnosis of
mumps orchitis).4

Mr R. Mukherjee, MD, FRCS(Urol), Specialist Registrar in Urology;

Mr A.M. Sinclair, FRCS(Urol), Consultant Urological Surgeon,
Stepping Hill Hospital, Stockport Foundation Trust

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BOX 1. Classification of epididymoorchitis1

ACUTE BACTERIAL
G Urinary tract infection, including
sexually transmitted infections,
tuberculosis, syphilis
ACUTE NON-BACTERIAL
G Viral, fungal, parasitic,
eg brucellosis, Cryptococcus
ACUTE NON-INFECTIOUS
G Idiopathic
G Traumatic
G Autoimmune granulomatous or
sarcoid (rare)
G Amiodarone-induced (rare)
CHRONIC
G Continuous
G Intermittent
In susceptive risk groups, epididymoorchitis may be the only focus of
genitourinary tuberculosis, where it
presents as a painless, slightly tender
scrotal mass and, in some instances,
abscess formation. The epididymis, vas
and spermatic cord become beaded on
palpation in chronic cases. Infection is
thought to result from direct extension
from the prostate and seminal vesicles, but
haematogenous spread may also occur.
Chronic epididymitis (symptoms for more
than six weeks) results in around 15 per
cent of acute episodes.3 As with chronic
cystitis or recurrent urinary tract infection,
it may be caused by an inadequately
treated initial infection (eg a persistent
bladder or prostatic source), resulting
in relapse/persistence of symptoms.
Alternatively, these may be the result of
true de-novo recurrent infections, usually
because of an underlying risk factor.
DIFFERENTIAL DIAGNOSIS
Patients present classically with acute pain
and swelling, with localised tenderness in
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the epididymis, with or without

involvement of the testis and spermatic
cord (with pain radiating to the groin/lower
abdomen). The swelling may eventually
result in a global red hemiscrotal mass,
with the testis indistinguishable from the
epididymis. The overlying skin may become
erythematous and a reactive hydrocoele
may also result. Systemic symptoms,
particularly a temperature, can occur. In
addition patients may have co-existing
or preceding symptoms of prostatitis,
urethritis or cystitis, depending on the
source of infection.
Although epididymitis should always be
considered in the differential diagnoses for a
patient presenting with acute scrotal pain, it
is essential to exclude testicular torsion,
particularly in the adolescent age group.
Differential features are listed in Table 1,
but it is important to bear in mind that
testicular torsion is the cause of 90 per cent
of cases of acute scrotal pain in patients
between 13 and 21 years.6 Testicular torsion
can also occur in older patients, and
therefore surgical exploration must be
considered the ultimate investigative
measure when any doubt exists.
Testicular tumours may also present in a
similar fashion, particularly if the rete
testis is involved (resulting in tubular
obstruction and pain). In addition,
haemorrhage and superimposed infection
may also result in pain and swelling,
precluding adequate palpation of the
underlying testicular lesion. As a result,

up to one-third of cases may be treated

with antibiotics initially, delaying referral
and definitive management.7 Other
differentials include trauma to the testis
with resulting haematocoele and possible
breach of the tunica albuginea (requiring
ultrasonic assessment or surgical
exploration if any doubt exists).
Fourniers gangrene (necrotising fasciitis of
the scrotum and perineum) should also be
borne in mind with regards to scrotal pain
and swelling, particularly for high-risk
groups, eg patients with diabetes,
immobilised with multiple medical
comorbidities. It presents with a classic
triad of severe pain (out of proportion
to the physical findings), swelling and
fever. The infective process involves a
subcutaneous synergistic infection with
secondary cellulitis (non-blanching) and
gangrene of the overlying skin, with no
involvement of the testis and epididymis.
Prompt radical surgical debridement is
required to prevent progression to septic
shock, multi-organ failure and death.8
In addition, referred pain from a ureteric
stone can present in a similar fashion
when no localising signs are present
despite acute pain. Non-urological
causes would include acute incarcerated
inguino-scrotal hernia.
Chronic infective epididymitis may
be difficult to differentiate from
epididymyalgia/orchialgia in terms of
clinical signs, in a similar fashion to

Features

Epididymo-orchitis

Testicular torsion

Onset
Site
Urinary symptoms
Pain
Urinalysis
Ultrasound features

Gradual to rapidly progressive

Epididymis testis/cord
Often
Mild to severe
Nitrites/leucocytes/blood
Increased flow/hyperaemia

Treatment

Antibiotics

Sudden
Testis/cord
Sometimes
Severe
Normal
Non-diagnostic (may show
impaired flow)
Surgical

Table 1. Comparison of features between epididymo-orchitis and testicular torsion

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chronic prostatitis/pelvic pain syndrome.

There may be an indurated, thickened or
even hard epididymis, which may require
ultrasonic follow-up to rule out a rare
adenomatoid tumour.9 Finally, a history
of previous vasectomy may implicate
postvasectomy discomfort/syndrome as
a potential source of symptoms (present
in 1015 per cent of patients following
vasectomy).10 In all such cases, intermittent
relapsing or almost constant symptoms
may well have a considerable impact on
quality of life.
INVESTIGATIONS
Baseline investigations for suspected
epididymo-orchitis (with no suspicion of
testicular torsion) include:
urinalysis and midstream specimen urine
Gram staining urine/urethral smear
to look for intracellular Gram-negative
diplococci (N. gonorrhoea) or white cells
(C. trachomatis in two-thirds), particularly
if urethral discharge is present
urethral swab for culture and sensitivity
(prior micturition), or urine polymerase
chain reaction for C. trachomatis and
N. gonorrhoea
serum inflammatory marker if sepsis,
monitor response as inpatient
ultrasound with Doppler flow to confirm
hyperaemic testicle/epididymitis. This
should be used as an adjunct and not to
exclude torsion, as ultrasound is only 80
per cent sensitive for diagnosing torsion.11
Additional investigations include:
intravenous urogram if ureteric colic
is suspected (eg normal clinical
examination with testicular pain)
flowmetry and postvoid residual (or
formal prostate/lower urinary tract
symptoms assessment) in men over
50 years old.
MANAGEMENT
Baseline management for acute
epididymo-orchitis is summarised in Box 2.
For chronic cases, intermittent therapeutic
trials of prolonged (46 weeks) antibiotics
TRENDS IN UROLOGY & MENS HEALTH

DECEMBER 2010

BOX 2. Acute treatment of epididymo-orchitis

CONSERVATIVE
G Bed rest/scrotal elevation and support
ANALGESIA
G Non-steroidal anti-inflammatory drugs
ANTIBIOTICS
G Treat empirically until culture and sensitivities return to avoid
progression/complications, as per local drug policies for regimen.
For example:
G Over-35s (sexually transmitted infection unlikely)
oral fluoroquinolone (allows for superior tissue penetration) or
co-amoxiclav for 1014 days
intravenous co-amoxiclav gentamicin if inpatient for sepsis
G Under-35s (sexually transmitted infection more likely)
doxycycline 100mg twice daily (or levofloxacin for more broad-spectrum
cover) for 14 days
STEROID THERAPY
G Recommended in European Association of Urology Guidelines3 in young men
to reduce infertility risk, but not currently standard UK practice
G Methylprednisolone 40mg/day, and reduce the dose by half every second day
similar to chronic prostatitis12 with
non-steroidal analgesia may be
sufficient in some cases. When infective
causes have been excluded, referral
to a chronic pain specialist should be
considered. Chronic pain specialists
use neuromodulatory analgesics (eg
gabapentin, pregabalin and amitriptyline)
and nerve/cord blocks with variable
success. It is important to emphasise
to patients that surgical interventions
(ultimately orchidectomy) may not lead
to resolution of symptoms, although
reversal of vasectomy and even
epididymectomy may achieve a degree
of success in postvasectomy orchialgia.13
Indications for referral are summarised
in Box 3.
Complications are uncommon, but may
include abscess formation, requiring
surgical drainage; ischaemia/infarction,
resulting in atrophy; persisting hydrocoele;
chronic epididymitis/chronic pain, and
infertility.

BOX 3. Indications for referral

G Suspected torsion
G Symptoms not resolving with
treatment in terms of antibiotic
courses and pain control
G Suspected septicaemia or abscess
formation
G Genitourinary medicine
assessment if sexually transmitted
infection suspected (contact
tracing, etc.)
G Paediatric urological assessment
in young for any congenital
abnormalities if recurrent
problem (as with urinary tract
infections)
G Suspected chronic epididymitis
where symptoms have not
resolved with simple analgesics
and prolonged repeated antibiotic
courses to rule out anatomical
sources of recurrent infection
(prostate/bladder)

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CONCLUSION
Epididymo-orchitis is a common urological condition
presenting to both primary and secondary care. Although
the majority of cases resolve with antibiotics, it is
important to be aware of potential complications and
alternative diagnoses as these can lead to long-term
morbidity.
Declaration of interests: none
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