The epididymis is a series of small tubes, attached to the back of each testicle, that collects and stores sperm. One of the most common causes of scrotal pain is epididymitis, which is infection and subsequent inflammation of these coiled tubes. Epididymo-orchitis occurs when the infection spreads to include the testicle. Epididymitis is usually a secondary bacterial infection that is triggered by a range of conditions, such as urinary tract infections or sexually transmitted diseases.
The bacteria in the urethra (the tube that allows the exit of urine and sperm from the penis) simply back-track through the urinary and reproductive structures to the epididymis. Treatment options include antibiotics and bed rest. Some men develop chronic epididymitis, which is characterised by inflammation even when there is no infection.
If each testicle is rolled gently between the fingers and thumb, a comma-shaped lump can be felt draped over the top. This "lump" is a narrow tightly coiled-up tube. If the coils were stretched out, the tube would measure 20 feet - over three times average male height. The lumps are the epididymes (plural), which is Greek for "upon the twins." When sperm are made, they enter the epididymis, and are stored while they mature. They need this extra time to develop before they set out on the long journey in the race for the egg. Epididymitis is an infection of the epididymis, the comma-shaped lumps which "sit upon the twins."
In youth, the infection can be due to sexually transmitted infection from chlamydia or gonorrhea and is associated with urethritis (inflammation of the urethra). In older men over 40, it is associated with urinary tract infections and prostatitis. Acute epididymitis causes swelling of the scrotum, pain in the testicles, and sometimes a fever of six weeks duration or less (usually with a gradual onset over several days).
If not treated, or in some other cases, the condition can become chronic. In chronic cases, there is usually no swelling, but simply pain. The incidence is approximately 600,000 cases per year. The highest prevalence is in young men 19 to 35 years of age. The disorder is a major cause of hospital admissions in the military (causing approximately 20% of admissions). Epididymitis is caused by spread of infection from the urethra or the bladder. The most common organisms involved in the condition in young heterosexual men are gonorrhoea and chlamydia. In children and older men, typical uropathogens, such as coliform oraganisms (E. coli), are much more common. This is also true in the case of homosexual men.
Mycobacterium tuberculosis (TB) can manifest also as epididymitis. "Beadlike" irregularities along vas deferens are the characteristic sign of this condition. Other bacteria (such as Ureaplasma) can also cause epididymitis. A non-infectious cause of epididymitis is the use of anti-arrhythmic medication, amiodarone. Here, the inflammation is limited to the head of the epididymis and does not respond to anti-microbial therapy. The treatment is dosage reduction or change of medications.
An increased risk is associated with sexually active men who are not monogamous and do not use condoms. Men who have recently had surgery or have a history of structural problems involving the genito-urinary tract are also at increased risk (regardless of sexual behaviors). Other risk factors include chronic indwelling urethral catheter use and being uncircumcised. Epididymitis may begin with a low grade fever and chills and a heavy sensation in the testicle. The testicle becomes increasingly sensitive to pressure or traction.
There may be lower abdominal discomfort or pelvic discomfort, and urination may cause burning or pain. On occasion, there may be a discharge from the urethra, blood in the semen, or pain on ejaculation. The testicle may enlarge significantly and produce severe pain. It is important that this condition be distinguished from testicular torsion (a reduction or stoppage of the blood flow to the testicle) which requires emergency care. Testicular torsion is a surgical emergency and should be treated as soon as possible. Acute testicular pain should never be ignored.
The main symptoms are fever and pain, developing progressively over several hours, in the back portion of the testicles. Symptoms include fever and chills, pain in the groin, and tender, swollen epididymes. Sudden pain in the scrotum, rapid unilateral scrotal enlargement, and marked tenderness of the testes, spermatic cord, and groin are characteristic manifestations. Symptoms may follow acute physical strain (heavy lifting), trauma, or sexual activity. There may also be pain at the tip of the penis and urethral discharge. Secondary orchitis with a swollen, painful testicle may occur. Orchitis is the generic name for any inflammation of the testicles. The symptoms of epididymitis and orchitis are much the same. Sometimes the names are used interchangeably. The symptoms of both are reddened scrotum, tense swollen testicles with sudden acute pain and fever. Orchitis can also be the result of a sports injury, or after surgery to remove a scrotal cyst, or vasectomy.
The diagnosis of acute epididymitis is established on the basis of history and physical findings. Urinalysis and urine culture may help to confirm the diagnosis. Additional tests may include gram-staining of a smear of urethral discharge and a scrotal ultrasound study.
Therapy is by antibiotics (often up to 3 weeks) and pain relief. Hospitalization is an option, depending on the degree of infection. Bed rest is essential until the pain subsides. If at home, raise and support the swollen scrotum on a soft pad for comfort. Avoid very hot compresses to soothe the inflammation; they can damage the sperm-making tubes. Application of ice bags may reduce pain. Non-steroidal anti-inflammatory drugs (NSAIDs) may be of use when there is evidence of a severe inflammatory process. Examination and treatment of the sexual partners of younger men with epididymitis should be done. Complications of acute epididymitis include abscess formation, testicular infarction, and the development of chronic pain and infertility. Prompt establishment of a diagnosis and initiation of treatment is therefore of the essence.
Because epididymitis that affects both testicles can make a man sterile, antibiotic therapy must be initiated as soon as symptoms appear. To prevent reinfection, medication must be taken exactly as prescribed, even if the patient's symptoms disappear or he begins to feel better. Over-the-counter anti-inflammatories can relieve pain but should not be used without the approval of a family physician or urologist. Bed rest is recommended until symptoms subside, and patients are advised to wear athletic supporters when they resume normal activities. If pain is severe, a local anesthetic like lidocaine (Xylocaine) may be injected directly into the spermatic cord.