BMJ Acute Epididymitis PDF

Acute epididymitis
The right clinical information, right where it's needed
Last updated: Nov 13, 2017

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 5
Prevention 6
Primary prevention 6
Secondary prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 8
History & examination factors 9
Diagnostic tests 10
Differential diagnosis 12
Treatment 14
Step-by-step treatment approach 14
Treatment details overview 15
Treatment options 16
Follow up 22
Recommendations 22
Complications 22
Prognosis 23
Guidelines 24
Diagnostic guidelines 24
Treatment guidelines 24
Evidence scores 26
References 27
Disclaimer 29
Summary
◊ Inflammation of the epididymis causing pain and swelling, which is usually unilateral and develops
over the course of a few days.
◊ In sexually active men (aged <35 years), epididymitis is most commonly caused by Chlamydia
trachomatis or Neisseria gonorrhoeae .
◊ In older men, the causative organisms are usually enteric pathogens, and epididymitis may be
associated with bladder outlet obstruction, recent instrumentation of the urinary tract, or systemic
illness.
◊ Diagnostic tests include a Gram stain of urethral secretions, taken as a urethral swab, prior to
obtaining a urine specimen for nucleic acid amplification tests for both C trachomatis and N
gonorrhoeae .
◊ Treatment relies on supportive measures, including bed rest, scrotal elevation, and analgesics,
in conjunction with empirical antibiotic therapy based on the patient's age and clinical and sexual
history.
◊ If C trachomatis or N gonorrhoeae are the confirmed or suspected pathogens, patients should be

strongly advised to refer their sexual partner(s) for evaluation and treatment.
Acute epididymitis Basics
Definition
Acute epididymitis is inflammation of the epididymis characterised by scrotal pain and swelling of less than
6 weeks' duration. It may be associated with irritative lower urinary tract symptoms, urethral discharge,
BASICS
and fever. It is usually unilateral. The condition is referred to as acute epididymo-orchitis if concurrent
inflammation of the testis is present. The acute presentation of epididymitis will be covered.
Epidemiology
US and European data concerning the incidence and prevalence of acute epididymitis are limited, as the
condition is not subject to national surveillance. In 1977, an estimated 634,000 patients sought medical
treatment for epididymitis in the US.[5] A study in Canada showed that 0.9% of 8712 men seen at an
outpatient practice over a 2.5-year period presented with epididymitis.[6] Another study, undertaken in
Europe, has estimated the incidence of epididymitis at 1.2 per 1000 male children.[7]
In the US, Healthcare Cost and Utilization Project data have shown little change in the number of hospital
admissions with acute epididymitis since 1996.[8] The Veterans' Affairs outpatient clinic dataset for 2001
reported a rate of 50 cases of epididymitis per 100,000 outpatient visits, with comparable rates in all 10-year
age categories from 25 to 34 years through to 55 to 64 years (61 per 100,000 to 73 per 100,000).[8] The
highest rates were seen among black people (87 per 100,000) and people residing in developed countries
(57 per 100,000).
Aetiology
Acute epididymitis is most commonly caused by bacterial infection.[9]
In men >35 years, the majority of cases are due to non-sexually transmitted infection with common
uropathogens, such as Escherichia coli and Enterococcus faecalis .[9] [10] In this group, infection may also
be associated with other risk factors, such as bladder outlet obstruction, recent instrumentation of the urinary
tract, or systemic illness.
Among men <35 years, infection is commonly transmitted via sexual intercourse, and causative organisms
include Chlamydia trachomatis and Neisseria gonorrhoeae .[11] It must be noted that enteric pathogens
may also be the causative agents in men who are the insertive partner in anal intercourse.[12]
The delineation of these groups by age is arbitrary, and a degree of crossover exists in terms of aetiology.
This underlines the importance of taking a thorough patient history, including a sexual history.
Rare causes of acute epididymitis include a reversible sterile epididymitis resulting from therapy with the
anti-arrhythmic drug amiodarone,[2] and an association with vasculitic processes in Behcet's syndrome and
Henoch-Schonlein purpura.[3] [4] Tuberculous epididymitis may occur in endemic areas. Viral epididymitis is
rare in the adult population, but an increase of mumps epididymitis has been seen in the UK due to the 2005
mumps epidemic in a cohort of non-immunised adults.[1]
Pathophysiology
Retrograde ascent of urinary pathogens from the urethra and bladder, via the ejaculatory ducts and vas
deferens, leads to colonisation and inflammation of the epididymis. The inflammatory process starts in the
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2017. All rights reserved.
Acute epididymitis Basics
tail of the epididymis and subsequently spreads to the body and head of the epididymis. In many cases,
the testis is involved in the inflammatory process, and the condition is referred to as epididymo-orchitis. The
mechanism underlying non-bacterial epididymitis, whether drug-induced or vasculitic, is unknown.
BASICS
Classification
Classification based on aetiological factors
Bacterial infection
• Sexually transmitted infection ( Chlamydia trachomatis and Neisseria gonorrhoeae in men <35 years;
enteric pathogens in men who are the insertive partner in anal intercourse).
• Non-sexually transmitted infection (enteric pathogens, such as Escherichia coli , or TB).
Viral
• Mumps orchitis should be considered given a rise in cases of mumps in non-immunised adults in the
UK.[1]
Drug-induced
• A reversible, sterile epididymitis is a rare adverse effect of therapy with the anti-arrhythmic drug
amiodarone.[2]
Vasculitic
• Rare cases of epididymitis have been reported in patients with Behcet's syndrome and Henoch-
Schonlein purpura.[3] [4]
Idiopathic
• No apparent risk factors, and cause remains unknown.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
5
Acute epididymitis Prevention
Primary prevention
For sexually transmitted acute epididymitis, prevention relies on protected intercourse using sheath condoms.
Consideration should be given to the use of antibiotic prophylaxis in older men who have known bladder
outflow obstruction and are undergoing procedures involving instrumentation of the urinary tract. These
reduce the risk of UTIs and hence are likely to reduce risk of epididymitis, although there is no clear
supportive evidence.
Secondary prevention
In cases of sexually transmitted acute epididymitis, it is prudent for the treating physician to discuss safe
sex practices and barrier protection. Avoidance of sexual contact until completion of treatment of the patient
and all sexual partners will help to prevent re-infection. Patients with a proven sexually transmitted infectious
epididymitis should be referred for screening for other sexually transmitted diseases.
PREVENTION
In non-sexually transmitted acute epididymitis, general hygiene issues should be discussed alongside
the evaluation of the patient's risk factors and investigation and treatment of any underlying urinary tract
pathology.
Acute epididymitis Diagnosis
Case history
Case history #1
A 21-year-old man presents with a 3-day history of worsening left-sided scrotal pain and swelling. He
reports noticing a white urethral discharge over the last 24 hours. He is otherwise fit and well, and takes
no regular medicine. He is heterosexual and has a single female partner, with whom he has unprotected
intercourse. Examination reveals a tender, erythematous, swollen left hemiscrotum with a palpably
thickened epididymis.
Case history #2
A 74-year-old man with a known history of benign prostatic enlargement and insulin-requiring type 2
diabetes presents with a 7-day history of worsening right-sided scrotal pain and swelling. Initial symptoms
of dysuria and frequency have resolved since his family doctor prescribed a course of antibiotics 4 days
ago. Examination reveals a tender, swollen right epididymis with an associated hydrocele.
Other presentations
Acute epididymitis from all causes presents in a similar way.
Step-by-step diagnostic approach

The clinical presentation of acute epididymitis is typically of unilateral pain and swelling of the scrotum. The
most important differential diagnosis to consider is that of testicular torsion, particularly when the onset of
pain is sudden and severe, and initial examination and tests show no evidence of inflammation or infection.
Risk factors
DIAGNOSIS
These include unprotected sexual intercourse. A history of anal intercourse may be associated with
infection due to enteric organisms. Uncommon risk factors include history of mumps[1] or infection
or contact with tuberculosis. In older men, infection with enteric organisms is associated with bladder
outlet obstruction, urinary tract infection, recent instrumentation of the urinary tract, or systemic illness,
particularly immunosuppression.
Clinical evaluation
A full patient history is of vital importance in determining the likely aetiopathology of acute epididymitis.
In particular, a sexual history should be sought, along with any history of pre-existing lower urinary tract
symptoms or recent instrumentation. Together with the age of the patient, these factors will allow the likely
causative agents to be determined and appropriate empirical antibiotic treatment to be instigated prior to
the results of diagnostic tests.
Examination may reveal a hot, erythematous, swollen hemiscrotum, with tender enlargement of the
epididymis. Diffuse enlargement of the testis will be present in epididymo-orchitis. Purulent discharge
may be present at the urethral meatus. In severe cases, the patient may be febrile and systemically ill.
7
Abscess formation may be evident by fluctuance of the swelling and induration of the overlying scrotal
tissue.
The clinical features of non-infectious epididymitis are the same as those with an infectious cause, but
patients may have a history of amiodarone use or symptoms of vasculitis, such as a rash, and will not
usually have a high fever or other symptoms of sepsis.
Investigations
Investigations are indicated to determine the underlying cause of epididymitis.
A urethral swab taken prior to micturition should be sent for Gram stain and culture of urethral secretions.
This test is highly sensitive and specific for documenting urethritis and the presence or absence of
gonococcal infection.
A urine dipstick test that is positive for leukocytes is suggestive of infection of the lower urogenital tract,
and a first-void urine sample should be sent for urine microscopy and culture. Nucleic acid amplification
testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae on the first-void urine sample has
a higher sensitivity compared with culture and is the preferred test for patients in whom these infections
are suspected.
Colour duplex ultrasonography is indicated for patients with signs suggestive of abscess formation or
possible testicular torsion.[14] Surgical exploration may be indicated in cases where testicular torsion
cannot be confidently excluded.
Non-infectious causes of epididymitis are usually evident from the history of amiodarone use or
underlying vasculitis and are confirmed through negative tests for bacterial infection. Three early morning
urines for alcohol- and acid-fast bacteria (AAFB) are indicated in patients suspected of having TB.
Idiopathic epididymitis is a diagnosis of exclusion.
Risk factors
DIAGNOSIS
Strong
unprotected sexual intercourse
• In men <35 years, acute epididymitis is most commonly caused by sexually transmitted pathogens
such as Chlamydia trachomatis and Neisseria gonorrhoeae .[12]
• Homosexual men are at risk of acute epididymitis caused by the transmission of enteric pathogens
such as Escherichia coli during unprotected anal intercourse.[11]
bladder out flow obstruction

• In older men, obstructive urinary symptoms secondary to bladder neck obstruction, benign prostatic
hyperplasia, or urethral stricture are associated with an increased risk of acute epididymitis.[13]
• Incomplete bladder emptying and higher voiding pressures lead to reflux of infected urine into the
ductal system and spread of pathogens to the epididymis.
instrumentation of urinary tract
• Cystoscopic procedures and urethral catheterisation (intermittent and indwelling) increase the risk of
lower urinary tract infection.[9] Pathogens are then able to spread to the epididymis via the ejaculatory
ducts and vas deferens.
• It is important to remember that patients undergoing these procedures are also more likely to have
other underlying risk factors, such as bladder outflow obstruction.
Weak
immunosuppression
• Medical conditions that either predispose patients to infections or limit their ability to fight infections,
such as diabetes, myelosuppression, and HIV infection, will increase the risk of developing acute
epididymitis.
• Patients with severe immunosuppression are at risk of acute epididymitis secondary to infection with
atypical pathogens, such as mycobacteria and fungi.
vasculitis
• Most commonly Behcet's and Henoch-Schonlein purpura.
amiodarone
• Rare, but the most common drug-induced cause.
mumps
• Viral epididymitis is rare in the adult population, but an increase of mumps epididymitis has been seen
in the UK due to the 2005 mumps epidemic in a cohort of non-immunised adults.[1]
exposure to TB
• Rare cause.
History & examination factors
DIAGNOSIS
Key diagnostic factors
presence of risk factors (common)
• These include sexual partners infected with Chlamydia trachomatis and Neisseria gonorrhoeae
; history of anal intercourse, which may be associated with infection due to enteric organisms;
history of viral infection (mumps, coxsackievirus, varicella, and echovirus); or infection or contact
with tuberculosis. In older men, infection with enteric organisms is associated with bladder outlet
obstruction, urinary tract infection, recent instrumentation of the urinary tract, or systemic illness,
particularly immunosuppression.
age <35 years: more likely to have sexually transmit ted infection (common)
• Sexually transmitted infections, such as Chlamydia trachomatis and Neisseria gonorrhoeae , are the
most common causative agents.[12]
older man: more likely to have infection with enteric organisms (common)
• Common enteric pathogens, such as Escherichia coli , are the causative agents.[9] [10]
9
unilateral scrotal pain and swelling of gradual onset (common)
• Pain and swelling typically develops over the course of a few days (unlike testicular torsion, which is
usually of sudden onset).
symptoms <6 weeks' duration (common)

• Symptoms over 6 weeks' duration indicate chronic inflammation.
tenderness (common)
• The epididymis can be felt as a tubular structure that lies posterior to the testis and runs in a sagittal
plane.
hot, erythematous, swollen hemiscrotum (common)

• Diffuse enlargement of the testis will be present in epididymo-orchitis.
frequent and painful micturition (uncommon)

• Common feature of lower urinary tract infection.
purulent urethral discharge (uncommon)

• Suggests sexually transmitted infection.
Other diagnostic factors

pyrexia (uncommon)
• Systemic upset is more suggestive of an infectious cause.
fluctuant swelling or induration of scrotal tissue (uncommon)

• May represent abscess formation.
Diagnostic tests
DIAGNOSIS
1st test to order
Test Result
Gram stain of urethral secretions ≥5 WBC per oil immersion
field; presence of
• A urethral swab is taken prior to micturition.
intracellular gram-
• Gram stain of the urethral secretions is highly sensitive and
negative diplococci
specific for documenting urethritis and the presence or absence of
gonococcal infection.
urine dipstick test positive leukocyte
esterase test shown as
• If dipstick testing of the first-void urine shows positive for WBC, it is
colour change on the
suggestive of urethritis and lower urinary tract infection.
reagent strip
urine microscopy ≥10 WBC per high-power

field
• First-void urine sample.
• Confirms initial urine dipstick test result.
• Can be used if dipstick testing not available.
Test Result
urine culture isolate of causative
organism
• A mid-stream urine specimen is required.
• Culture identifies non-gonococcal, non-chlamydial urinary pathogens.
nucleic acid amplification test (NAAT) of urethral secretions or may be positive
first-void urine for C trachomatis and N gonorrhoeae
• NAAT for C trachomatis and N gonorrhoeae on the first-void urine
sample has a higher sensitivity compared with culture and is the
preferred test for patients in whom these infections are suspected.
culture of urethral secretions positive culture of
N gonorrhoeae or C
• Test takes several days to yield a result.
trachomatis
Other tests to consider
Test Result
colour duplex ultrasonography epididymis is enlarged
and hyperaemic,
• Colour duplex ultrasonography has a sensitivity of 96% and a
with a low-resistance
specificity of 84% to 95% in diagnosing acute epididymitis.[14] It
monophasic arterial
can also identify abscess formation and testicular infarction. Usually
a subsequent test, it may be used initially when severity of pain waveform pat tern; good
for localising areas of
prevents palpation of the epididymis.
inflammation, it may
be of particular use
when severity of pain
prevents palpation of the
epididymis and to confirm
the diagnosis in non-
infectious cases
surgical exploration oedematous epididymis
DIAGNOSIS
with vascular
• Standard scrotal exploration may be indicated in cases where
congestion and
testicular torsion cannot be confidently excluded.
evidence of surrounding
inflammatory reaction,
with no evidence of
testicular torsion or other
pathology
3 early morning urines for alcohol- and acid-fast bacilli (AAFB) may be positive
• Indicated when tuberculous epididymitis suspected.
11
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Testicular torsion • Usually presents with • Negative Prehn's sign: there
sudden-onset severe is no pain relief when the
unilateral scrotal pain. affected hemiscrotum is
• Should be considered as a elevated.
differential diagnosis in all • Colour duplex
male patients presenting ultrasonography has been
with acute scrotal pain, shown to be useful in
particularly when there is an differentiating between
absence of symptoms and torsion and inflammatory
signs relating to an infectious pathology in cases where
cause, such as urinary the history and clinical
frequency, painful micturition, findings are equivocal.[15]
and urethral discharge. • However, there should be
• Occurs more frequently in no delay in performing
adolescents, but can occur scrotal exploration in cases
in all age groups. where testicular torsion
is considered a likely
differential diagnosis.
Acute idiopathic scrotal • Usually affects the paediatric • Usually diagnosed clinically.
oedema population, but has been Ultrasonography can
reported in adults.[16] be used to confirm the
• Acute onset of redness diagnosis.
and oedema, but usually
painless.
• Can be unilateral or bilateral.
Infected hydrocele • History of pre-existing • Ultrasonography confirms

hydrocele. the presence of a hydrocele
containing turbid fluid, with a
DIAGNOSIS
normal appearance of, and

blood flow to, the epididymis
and testis.
Strangulated inguinal • History of previous • Usually diagnosed clinically.

hernia intermittent inguinoscrotal
swelling, with or without pain.
• Sudden onset of pain and
inability to reduce the hernia.
Associated nausea and
vomiting.
• May be difficult to palpate
the testis and epididymis
with a large strangulated
inguinal hernia.
Condition Differentiating signs / Differentiating tests

symptoms
Testicular tumour • Usually a painless swelling • Ultrasonography will confirm
of gradual onset, but can the presence of a testicular
mimic an epididymitis tumour.
in some malignant
presentations. This is usually
due to the presence of a
superior polar tumour in the
rete testis.
DIAGNOSIS
13
Acute epididymitis Treatment
Step-by-step treatment approach

The general goals in the treatment of acute epididymitis are:
• Symptomatic relief
• Eradication of infection if present
• Prevention of transmission to others (sexually transmitted epididymitis)
• Prevention of potential complications (e.g., abscess formation, infertility, or chronic pain/epididymitis).
Symptomatic relief
Bed rest, scrotal elevation, and simple analgesia are the main supportive therapies in the treatment of
acute epididymitis regardless of the aetiopathology of the condition. Such measures are recommended
until signs of local inflammation or fever have resolved. If the patient is systemically ill with high-grade
fever, admission to hospital for IV antibiotics and fluids is indicated. In drug-induced acute epididymitis
due to amiodarone, dose reduction or discontinuation of the drug results in rapid resolution of the
symptoms. Vasculitic epididymitis resolves with conservative measures and treatment of the underlying
cause. This may necessitate specialist input from a rheumatologist, as severe cases of vasculitis can
require treatment with systemic corticosteroids and immunosuppressive agents.
Eradication of infection
In cases where bacterial infection is the presumed causative factor, empirical antibiotic treatment is
indicated before laboratory tests are available. The choice of antibiotics will depend on the age of the
patient and their associated risk factors, including history of unprotected intercourse, recent urinary tract
instrumentation, bladder outflow obstruction, or systemic disease/immunosuppression.
In cases where epididymitis may be caused by gonococcal or chlamydial1[C]Evidence infection,

ceftriaxone plus doxycycline is recommended as initial empirical therapy.[10] [17] However, some
guidelines recommend the use of ceftriaxone only once Neisseria gonorrhoeae is confirmed.[18]
For acute epididymitis most likely to be caused by enteric organisms, the use of a quinolone (e.g.,
ofloxacin or levofloxacin) is recommended. Because of high resistance rates, quinolones are no longer
recommended for suspected sexually transmitted disease.
Other causes are unusual. Mumps epididymitis is treated with supportive care. TB epididymitis should
be treated with systemic antibiotics according to local guidelines, due to highly variable TB strains and
antibiotic resistance patterns.
Prevention of potential complications

Prompt treatment and supportive measures will limit the overall severity of the condition and thereby
reduce the risk of developing complications. Prompt empirical antibiotic therapy may prevent abscess
formation and thus avoid the need for hospitalisation and surgery.[19] Testicular ischaemia/infarction is a
rare complication of severe epididymitis, which may lead to problems with sub-fertility/infertility. Although
TREATMENT
up-to-date data are limited, the use of corticosteroids has not been shown to confer any significant
benefit in reducing the long-term sequelae of epididymal obstruction secondary to inflammation.[20] The
development of chronic pain/epididymitis following acute epididymitis is rare, and little is known about its
aetiology and pathogenesis.[21]
Treatment details overview

Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )
Acute ( summary )
Patient group Tx line Treatment
infectious: likely to be sexually 1st empirical ceftriaxone plus dox ycycline

transmit ted
plus supportive measures
with possible enteric adjunct quinolone

infection
infectious: not sexually 1st empirical quinolone

transmit ted
amiodarone-induced 1st dose reduction or discontinuation of drug
underlying vasculitis 1st specialist referral to a rheumatologist
idiopathic or viral 1st supportive measures
tuberculous 1st anti-tuberculous antibiotics, specialist

referral, and supportive measures
TREATMENT
15
Treatment options
Acute
infectious: likely to be sexually 1st empirical ceftriaxone plus dox ycycline

transmit ted
» Among men aged <35 years who are
sexually active, acute epididymitis is most
frequently caused by Chlamydia trachomatis
or Neisseria gonorrhoeae . In cases where
epididymitis may be caused by gonococcal or
chlamydial1[C]Evidence infection, ceftriaxone
plus doxycycline is recommended as initial
empirical therapy.[10] [17] However, some
guidelines recommend the use of ceftriaxone
only once N gonorrhoeae is confirmed.[18]
» Patients should be advised to avoid

unprotected sexual intercourse until they and
their partner(s) have completed treatment.
» A quinolone (ofloxacin or levofloxacin) can

be used in patients who, on further testing, are
negative for chlamydia or gonorrhoea (because
of high resistance rates, quinolones are no
longer recommended for suspected sexually
transmitted disease).
Primary options
» ceftriaxone: 250 mg intramuscularly as a

single dose
-and-
» doxycycline: 100 mg orally twice daily for 14
days
» Bed rest and scrotal elevation are
recommended until signs of local inflammation or
fever have resolved.
» Analgesics such as paracetamol should be

continued until fever and local inflammation
subside.
» Non-steroidal anti-inflammatory drugs

(NSAIDs) may be of benefit.
» Non-selective NSAIDs may be added to

TREATMENT
paracetamol to reduce pain. The smallest

effective dose is used for the shortest possible
time or intermittently.
Acute
» If patients are systemically ill with signs
of sepsis, IV fluid replacement and initial IV
antibiotic therapy may be indicated.
Primary options
» paracetamol: 500-1000 mg orally every 4-6

hours when required, maximum 4000 mg/day
OR
Primary options
» naproxen: 250-500 mg every 12 hours

when required, maximum 1250 mg/day
OR
Primary options
» ibuprofen: 400-800 mg every 6-8 hours

with possible enteric adjunct quinolone
infection
» If test results are negative for Neisseria
gonorrhoeae or infection is likely to be
caused by enteric organisms (history of anal
intercourse), then additional therapy with a
quinolone is recommended, because of high
resistance rates among such enteric infections.
Quinolones are no longer recommended for
suspected sexually transmitted disease.
Primary options
» ofloxacin: 300 mg orally twice daily for 10

days
OR
Primary options
» levofloxacin: 500 mg orally once daily for 10

days
infectious: not sexually 1st empirical quinolone

transmit ted
» Sexually transmitted epididymitis is relatively
uncommon in men >35 years; however,
bacteriuria secondary to bladder outlet
obstruction increases with increasing age.
TREATMENT
» Non-sexually transmitted epididymitis

is usually caused by enteric organisms
and is often associated with recent urinary
tract instrumentation, systemic disease, or
immunosuppression.
17
Acute
» Quinolones are the antibiotic of choice in this
patient group (because of high resistance rates,
quinolones are no longer recommended for
suspected sexually transmitted disease).
Primary options
» ofloxacin: 300 mg orally twice daily for 10

days
OR
Primary options
» levofloxacin: 500 mg orally once daily for 10

days

subside.



Primary options

OR
Primary options

OR
TREATMENT
Primary options

Acute
amiodarone-induced 1st dose reduction or discontinuation of drug
» Side effects of amiodarone, including
epididymitis, are known to be dose-dependent
and duration-dependent.[22]
» Signs and symptoms resolve rapidly following

dose reduction or cessation of therapy.


subside.



Primary options

OR
Primary options

OR
Primary options

TREATMENT
underlying vasculitis 1st specialist referral to a rheumatologist

» Vasculitis of the epididymis is rare but can
be due to Behcet's syndrome or to Henoch-
Schonlein purpura. Referral to a rheumatologist
is advised to establish the diagnosis and to
19
Acute
determine whether epididymal involvement is
part of a systemic vasculitic process, and to plan
appropriate treatment.


subside.



Primary options

OR
Primary options

OR
Primary options

idiopathic or viral 1st supportive measures

TREATMENT

subside.

Acute

Primary options

OR
Primary options

OR
Primary options

tuberculous 1st anti-tuberculous antibiotics, specialist

referral, and supportive measures
» TB epididymitis should be treated with
systemic antibiotics according to local guidelines,
due to highly variable TB strains and antibiotic
resistance patterns.
TREATMENT
21
Acute epididymitis Follow up
Recommendations
Monitoring
FOLLOW UP
Failure to improve within 3 days of commencing treatment should prompt re-evaluation of the diagnosis
and therapy. Persistence of symptoms may indicate abscess formation, testicular infarction, atypical
infections (tubercular or fungal epididymitis), or underlying tumour.
Patients with a proven sexually transmitted infectious epididymitis should be referred for screening for
other sexually transmitted diseases. The evaluation and treatment of all recent sexual partners is also
recommended.
In cases of non-sexually transmitted epididymitis caused by enteric pathogens, investigation for

underlying lower urinary tract pathology should be considered once the patient has fully recovered.
Patient instructions
During treatment of epididymitis, supportive patient measures will include bed rest and scrotal elevation
until signs of local inflammation or fever have resolved. Analgesics such as paracetamol may be
continued until fever and local inflammation subside. Non-steroidal anti-inflammatory drugs (NSAIDs)
may be of benefit. If patients are systemically ill with signs of sepsis, IV fluid replacement and initial IV
The rapid improvement in symptoms with treatment can lead to treatment non-adherence and recurrence.
Patients should be informed of the importance of completing the course of treatment to prevent
complications such as infertility due to epididymal obstruction or testicular atrophy.
In cases of sexually transmitted acute epididymitis, it is imperative that patients are educated regarding
the transmissibility of the condition and the potential long-term sequelae for them and their partners if
the condition remains untreated. The evaluation and treatment of all recent sexual partners is strongly
advised. Patients should be advised to avoid sexual intercourse until their treatment and that of their
sexual partner(s) is completed.
Complications
Complications Timeframe Likelihood

abscess formation short term low
The overall rate of abscess formation is 3% to 8%.[19]
Prompt antibiotic treatment will reduce the risk of abscess formation and thus reduce the need for
hospitalisation and surgery.
Surgical drainage may be required.
testicular ischaemia/infarction short term low
Acute epididymitis Follow up
Complications Timeframe Likelihood

Occlusion of the testicular blood vessels, due to involvement of the cord in the inflammatory process or
FOLLOW UP
from extrinsic compression by the oedematous epididymis, can lead to ischaemia or infarction of the testis.
Subsequent testicular atrophy may result in problems with sub-fertility or infertility.
Prompt treatment and resolution of the local inflammation will help to prevent this rare complication.
epididymal obstruction long term low
If infection is inadequately treated, the inflammatory process will ultimately lead to scarring and obstruction
of the epididymis. In the long term, this can result in sub-fertility or infertility.
The use of corticosteroids has not been shown to confer any significant benefit in reducing the risk of
developing epididymal obstruction.[20]
chronic pain following epididymitis long term low
The development of chronic pain following acute epididymitis is rare, and little is known about its aetiology
and pathogenesis.[21]
Current management relies on reassurance and supportive treatment with analgesics, with
epididymectomy considered only in extreme cases.
male factor infertility long term low
May be caused by surgery, obstruction, chronic inflammation, testicular ischaemia, or infarction.
Prognosis
In men with infectious acute epididymitis, symptoms usually resolve rapidly following the initiation of
appropriate antibiotic therapy. This rapid improvement can lead to treatment non-adherence and recurrence.
Inadequately treated infectious epididymitis, particularly sexually transmitted infection, can in rare cases lead
to epididymal obstruction or testicular atrophy and subsequent infertility problems.
23
Acute epididymitis Guidelines
Diagnostic guidelines
Europe
Guidelines on urological infections

Published by: European Association of Urology Last published: 2016
2010 United Kingdom national guideline for the management of epididymo-

orchitis
Published by: British Association for Sexual Health and HIV Last published: 2010
North America
Sexually transmit ted diseases treatment guidelines 2015

GUIDELINES
Published by: Centers for Disease Control and Prevention Last published: 2015
Summary: A differential diagnosis of testicular torsion should be considered in all cases. Gram stain
evaluation of urethral secretions for the presence or absence of gonococcal infection and urethritis
should be performed. Nucleic acid amplification test on a urine sample is the preferred test for Chlamydia
trachomatis infection. Patients who have been diagnosed with sexually transmitted epididymitis should
receive testing for other sexually transmitted diseases, and their recent partner(s) should also be screened.
ACR appropriateness criteria: acute onset of scrotal pain - without trauma,

without antecedent mass
Published by: American College of Radiology Last published: 2014
Treatment guidelines
Europe
Guidelines on paediatric urology

Guidelines on urological infections

Guidelines on male infertility

2010 United Kingdom national guideline for the management of epididymo-

orchitis
Published by: British Association for Sexual Health and HIV Last published: 2010
Acute epididymitis Guidelines
North America
Sexually transmit ted diseases treatment guidelines 2015

Published by: Centers for Disease Control and Prevention Last published: 2015
Summary: Empirical antibiotic therapy should be initiated before laboratory results are available.
All patients with possible sexually transmitted infectious epididymitis should receive a single dose of
ceftriaxone plus a course of doxycycline. If initial results are negative for gonococcal infection or an enteric
pathogen is likely, a quinolone should be used as additional therapy. Because of high resistance rates,
quinolones are no longer recommended for suspected sexually transmitted disease.
GUIDELINES
25
Acute epididymitis Evidence scores
Evidence scores
1. Cure rate: there is poor-quality evidence comparing doxycycline and tetracycline with other multiple-
dose antibiotics in increasing cure rates. Both doxycycline and tetracycline are associated with high
cure rates (95% to 100%) in subjects with chlamydia infection.
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized
controlled trials (RCTs) of <200 participants.
EVIDENCE SCORES
Acute epididymitis References
Key articles
• Nickel JC, Teichman JM, Gregoire M, et al. Prevalence, diagnosis, characterization, and treatment
REFERENCES
of prostatitis, interstitial cystitis, and epididymitis in outpatient urological practice: the Canadian PIE
Study. Urology. 2005;66:935-940. Abstract
• Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases
treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. Full text Abstract
• Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment
guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections.
MMWR Morb Mortal Wkly Rep. 2012:61;590-594. Full text Abstract
References
1. Street E, Joyce A, Wilson J; Clinical Effectiveness Group, British Association for Sexual Health and
HIV. 2010 United Kingdom national guideline for the management of epididymo-orchitis. 2010. http://
www.bashh.org (last accessed 13 June 2016). Full text
2. Gabal-Shehab LL, Monga M. Recurrent bilateral amiodarone induced epididymitis. J Urol.

1999;161:921. Abstract
3. Kaklamani VG, Vaiopoulos G, Markomichelakis N, et al. Recurrent epididymo-orchitis in patients with

Behçet's disease. J Urol. 2000;163:487-489. Abstract
4. Lee JS, Choi SK. Acute scrotum in 7 cases of Schoenlein-Henoch syndrome. Yonsei Med J.
1998;39:73-78. Abstract
5. Berger RE, Alexander ER, Harnisch JP, et al. Etiology, manifestations and therapy of acute
epididymitis: prospective study of 50 cases. J Urol. 1979;121:750-754. Abstract
6. Nickel JC, Teichman JM, Gregoire M, et al. Prevalence, diagnosis, characterization, and treatment
of prostatitis, interstitial cystitis, and epididymitis in outpatient urological practice: the Canadian PIE
Study. Urology. 2005;66:935-940. Abstract
7. Tekgül S, Dogan HS, Hoebeke R, et al; European Association of Urology. Guidelines on paediatric
urology. 2016. http://uroweb.org/ (last accessed 13 June 2016). Full text
8. Chorba T, Tau G, Irwin K. Sexually transmitted diseases. In: Litwin MS, Saigal CS, eds. Urologic
diseases in America. US Department of Health and Human Services, Public Health Service, National
Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington,
DC: US Government Printing Office; 2007: NIH Publication No. 07-5512:647-695.
9. Chan PT, Schlegel PN. Inflammatory conditions of the male excurrent ductal system: part I. J Androl.
2002;23:453-460. Full text Abstract
27
Acute epididymitis References
10. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases
treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. Full text Abstract
REFERENCES
11. Berger RE. Acute epididymitis: etiology and therapy. Semin Urol. 1991;9:28-31. Abstract
12. Berger RE, Kessler D, Holmes KK. Etiology and manifestations of epididymitis in young men:
correlations with sexual orientation. J Infect Dis. 1987;155:1341-1343. Abstract
13. Thind P, Brandt B, Kristensen JK. Assessment of voiding dysfunction in men with acute epididymitis.
Urol Int. 1992;48:320-322. Abstract
14. American College of Radiology. ACR appropriateness criteria: acute onset of scrotal pain - without
trauma, without antecedent mass. 2014. http://www.acr.org/ (last accessed 13 June 2016). Full text
15. Lin EP, Bhatt S, Rubens DJ, et al. Testicular torsion: twists and turns. Semin Ultrasound CT MR.
2007;28:317-328. Abstract
16. Shah J, Qureshi I, Ellis BW. Acute idiopathic scrotal oedema in an adult: a case report. Int J Clin Pract.
2004;58:1168-1169. Abstract
17. Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment
guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections.
MMWR Morb Mortal Wkly Rep. 2012:61;590-594. Full text Abstract
18. Pickard R, Bartoletti R, Bjerklund Johansen TE, et al; European Association of Urology. Guidelines on
urological infections. 2016. http://www.uroweb.org (last accessed 13 June 2016). Full text
19. Luzzi GA, O'Brien TS. Acute epididymitis. BJU Int. 2001;87:747-755. Abstract
20. Moore CA, Lockett BL, Lennox KW, et al. Prednisone in the treatment of acute epididymitis: a
cooperative study. J Urol. 1971;106:578-580. Abstract
21. Nickel JC. Chronic epididymitis: a practical approach to understanding and managing a difficult
urologic enigma. Rev Urol. 2003;5:209-215. Full text Abstract
22. Greene HL, Graham EL, Werner JA, et al. Toxic and therapeutic effects of amiodarone in the treatment
of cardiac arrhythmias. J Am Coll Cardiol. 1983;2:1114-1128. Abstract
Acute epididymitis Disclaimer
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Publishing Group Ltd ("BMJ Group") tries to ensure that the information provided is accurate and up-to-
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DISCLAIMER
29
Contributors:
// Authors:
Mary Garthwaite, MBBS, FRCS(Urol), PhD

Consultant Urologist
James Cook University Hospital, Middlesbrough, UK
DISCLOSURES: MG declares that she has no competing interests.
Ian Eardley, MB BChir, FRCS

Consultant Urologist
St James's University Hospital, Leeds, UK
DISCLOSURES: IE is a consultant to Pzifer, Lilly, and Sanofi. He is a speaker for Lilly.
// Peer Reviewers:
Stephen Payne, MB, MS, FRCS, FEBUrol

Consultant Urological Surgeon
Spire Manchester Hospital, Manchester, UK
DISCLOSURES: SP declares that he has no competing interests.
Edmund Sabanegh, Jr, MD

Director
Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH
DISCLOSURES: ES declares that he has no competing interests.

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Acute epididymitis

The right clinical information, right where it's needed

Last updated: Nov 13, 2017

◊ If C trachomatis or N gonorrhoeae are the confirmed or suspected pathogens, patients should be

• No apparent risk factors, and cause remains unknown.

Step-by-step diagnostic approach

bladder out flow obstruction

History & examination factors

symptoms <6 weeks' duration (common)

hot, erythematous, swollen hemiscrotum (common)

frequent and painful micturition (uncommon)

purulent urethral discharge (uncommon)

Other diagnostic factors

fluctuant swelling or induration of scrotal tissue (uncommon)

1st test to order

urine microscopy ≥10 WBC per high-power

Other tests to consider

surgical exploration oedematous epididymis

Condition Differentiating signs / Differentiating tests

Infected hydrocele • History of pre-existing • Ultrasonography confirms

normal appearance of, and

Strangulated inguinal • History of previous • Usually diagnosed clinically.

Condition Differentiating signs / Differentiating tests

Step-by-step treatment approach

In cases where epididymitis may be caused by gonococcal or chlamydial1[C]Evidence infection,

Prevention of potential complications

Treatment details overview

infectious: likely to be sexually 1st empirical ceftriaxone plus dox ycycline

plus supportive measures

with possible enteric adjunct quinolone

infectious: not sexually 1st empirical quinolone

plus supportive measures

amiodarone-induced 1st dose reduction or discontinuation of drug

plus supportive measures

underlying vasculitis 1st specialist referral to a rheumatologist

plus supportive measures

idiopathic or viral 1st supportive measures

tuberculous 1st anti-tuberculous antibiotics, specialist

infectious: likely to be sexually 1st empirical ceftriaxone plus dox ycycline

» Patients should be advised to avoid

» A quinolone (ofloxacin or levofloxacin) can

» ceftriaxone: 250 mg intramuscularly as a

» Analgesics such as paracetamol should be

» Non-steroidal anti-inflammatory drugs

» Non-selective NSAIDs may be added to

paracetamol to reduce pain. The smallest

» paracetamol: 500-1000 mg orally every 4-6

» naproxen: 250-500 mg every 12 hours

» ibuprofen: 400-800 mg every 6-8 hours

» ofloxacin: 300 mg orally twice daily for 10

» levofloxacin: 500 mg orally once daily for 10

infectious: not sexually 1st empirical quinolone

» Non-sexually transmitted epididymitis

» ofloxacin: 300 mg orally twice daily for 10

» levofloxacin: 500 mg orally once daily for 10

» Analgesics such as paracetamol should be

» Non-steroidal anti-inflammatory drugs

» Non-selective NSAIDs may be added to

» If patients are systemically ill with signs

» paracetamol: 500-1000 mg orally every 4-6

» naproxen: 250-500 mg every 12 hours

» ibuprofen: 400-800 mg every 6-8 hours

» Signs and symptoms resolve rapidly following