SUPPLEMENT ARTICLE

Epididymitis
Stephanie N. Taylor
Section of Infectious Diseases, Louisiana State University Health Sciences Center, New Orleans

In April 2013, the Centers for Disease Control and Prevention (CDC) convened an advisory group to assist in
development of the 2015 CDC sexually transmitted diseases (STDs) treatment guidelines. The advisory group
examined recent abstracts and published literature addressing the diagnosis and management of sexually trans-
mitted infections. This article summarizes the key questions, evidence, and recommendations for the diagnosis
and management of epididymitis that were considered in preparation of the 2015 CDC STD treatment
guidelines.
Keywords. epididymitis; urethritis; gonorrhea; chlamydia; scrotal pain.

Epididymitis is inflammation of the epididymis due to that were considered in development of the 2015 Cen-
infectious and noninfectious etiologies. When the testicle ters for Disease Control and Prevention sexually trans-
is also involved, it is referred to as epididymo-orchitis. mitted diseases (STDs) treatment guidelines.
Unfortunately, the true prevalence of epididymitis is
unknown. The most current published data report that
there are approximately 600 000 cases of epididymitis METHODS
per year in the United States [1]. Epididymitis accounted
Multiple PubMed database searches for articles about
for 1 in 144 outpatient visits (0.69%) made by men aged
epididymitis were conducted using the Medical Sub-
18–50 years in 2002 [1], and Nickel et al demonstrated
ject Heading “epididymitis,” including all documents
that 1% of men presenting to Canadian outpatient urol-
and subheadings. Searches were limited to English-
ogists had epididymitis [2]. In an article that examined
language articles published from December 2008 to
single and multiple health insurance claims for the di-
December 2012. The search generated 232 abstracts,
agnosis of epididymitis/orchitis in the United States be-
with 11 selected for more detailed review. These abstracts
tween 2001 and 2004, Bohm et al reported that 4636 of
were chosen for complete review and presentation at
316 418 males (1.5%) aged 14–35 years had at least 1
the meeting because the findings and/or conclusions
claim for epididymitis over that period [3]. It was also
answered the key questions put forth by the advisory
noted that 40.6% of the men resided in the southern
committee. The evidence presented in these articles
region of the United States, and a correlation between
also provided the basis for the committee treatment
epididymitis and high rates of sexually transmitted in-
recommendations.
fections in the south was observed. A bimodal distribu-
National conference final program abstract publica-
tion has also been noted, with a peak incidence in men
tions were also searched online including the Infectious
16–30 years of age and those 51–70 years of age [4].
Diseases Society of America 2008–2012 annual meet-
This article summarizes the key questions and evidence
ings (http://www.idsa.confex.com/idsa/archives.cgi);
related to diagnosis and management of epididymitis
the Interscience Conference on Antimicrobial Agents
and Chemotherapy (http://www.icaac.org/); the Inter-
Correspondence: Stephanie N. Taylor, MD, Section of Infectious Diseases, Lou- national Society for Sexually Transmitted Diseases Re-
isiana State University Health Sciences Center, 3308 Tulane Ave, New Orleans, LA
70119 (staylo2@lsuhsc.edu).
search 2009 and 2011 meetings (http://www.isstdr.org/
Clinical Infectious Diseases® 2015;61(S8):S770–3 previous-meetings.php); the American Urological As-
© The Author 2015. Published by Oxford University Press on behalf of the Infectious sociation 2009–2012 annual meetings (http://www.
Diseases Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
aua2012.org/abstracts/abstracts.cfm); and the National
DOI: 10.1093/cid/civ812 STD Prevention Conference 2004, 2006, and 2008

S770 • CID 2015:61 (Suppl 8) • Taylor

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 (http://cdc.confex.com/cdc/std2010/webprogram/start.html;
http://cdc.confex.com/cdc/std2012/webprogram/start.html).
CLINICAL PRESENTATION
Men and boys with epididymitis classically present with posterior
testicular pain that is gradual in onset, usually unilateral, and oc-
casionally radiates to the lower abdomen [1]. Acute epididymitis
is a clinical syndrome consisting of pain, swelling, and inflam-
mation of the epididymis that lasts <6 weeks [5]. Chronic epidid-
ymitis is characterized by a ≥6-week history of symptoms of
discomfort and/or pain in the scrotum, testicle, or epididymis.
Chronic epididymitis is also defined by some authors as pain of
at least 3 months’ duration [2, 5]. Other signs and symptoms such
as discharge, dysuria, frequency, urgency, erythema of the scrotal
skin, and fever may be present also. In addition, physical elevation
of the testicle or scrotum when a patient is standing decreases the
pain of epididymitis. This maneuver, known as the Prehn sign,
does not decrease the pain associated with testicular torsion [6, 7].
A high index of suspicion for testicular torsion must be main-
tained. Torsion usually presents with the acute onset of severe tes-
ticular pain. Acute scrotum is a clinical diagnosis and emergent
scrotal exploration is indicated. Surgery within 6 hours of presenta-
tion is mandatory to prevent infarction, necrosis, atrophy, and loss
of the testicle [1, 5–8]. Testicular torsion can occur at any age, but
Barada et al demonstrated that 65% of cases were present in 12- to
18-year-old males [9]. Torsion is rare in men >35 years of age.
Fournier’s gangrene must also be kept in mind because it may
begin insidiously with malaise and scrotal discomfort that be-
comes scrotal pain and scrotal or perineal skin discoloration
that progresses from erythema to ecchymosis and then to
black and frank necrosis [10]. Comorbid conditions such as di-
abetes, trauma, radiation, steroid therapy, AIDS, malignancy,
and cirrhosis may be present. Fournier’s gangrene is a necrotiz-
ing fasciitis of the perineum caused by a mixed infection with
aerobic/anaerobic bacteria resulting from a perirectal abscess,
trauma, circumcision, an insect bite, hemorrhoids, rectal biopsy,
and other insults to the perineal or genital area. Antibiotic ther-
apy alone is usually associated with a 100% mortality rate, high-
lighting the need for immediate referral to urology or surgery,
usually for extensive and wide surgical debridement.
Clinical indications for hospitalization as a result of epididy-
mitis include severe infection, bacteremia or sepsis, inability to
take oral medications due to nausea and vomiting, and the need
for surgical intervention when torsion, testicular abscess, or
Fournier’s gangrene is suspected.
ETIOLOGY OF EPIDIDYMITIS
Epididymitis is caused by multiple infectious, noninfectious,
and even postinfectious microbial agents and processes. In
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most cases of bacterial epididymitis, retrograde ascent of the or-
ganisms is the mechanism of infection. In other cases, such as
Mycobacterium tuberculosis, hematogenous spread or seeding
of the epididymis is the mechanism of infection [2, 5].
Bacterial agents responsible for epididymitis are highly depen-
dent upon age and sexual practices. Urinary tract pathogens, such
as Escherichia coli, are responsible for epididymitis in boys <14
years of age and men >35 years of age [1]. In older men, the ep-
ididymis becomes infected in the setting of bacteriuria secondary
to bladder outlet obstruction from prostatic hypertrophy, urinary
tract instrumentation, prostatic biopsy, or urologic surgery. Ana-
tomic abnormalities also contribute to the etiology of nonspecific
bacterial epididymitis caused by a variety of aerobic bacteria. In
sexually active men aged 14–35 years and in older men who have
sex with men, Neisseria gonorrhoeae and Chlamydia trachomatis
are the most common organisms. Men who practice insertive
anal intercourse are at risk for both common sexually transmitted
organisms and sexually transmitted coliforms such as E. coli [1].
Other bacterial organisms such as Pseudomonas aeruginosa,
Klebsiella pneumoniae, Haemophilus influenzae, Proteus mirabi-
lis, Ureaplasma urealyticum, and Mycoplasma genitalium have
also been associated with epididymitis [11].
Chronic epididymitis can be caused by M. tuberculosis and
other organisms that induce a granulomatous reaction [12, 13].
The source of the infection is not urinary tract seeding, but is
hematogenous spread and seeding of the epididymis. The diag-
nosis of tuberculous epididymitis is difficult to make because it
is difficult to isolate the organism from the urinary tract. Only
half of patients with tuberculosis of the urinary tract will have
successful isolation of the organism. Epididymitis secondary to
treatment of superficial bladder cancer with bacillus Calmette-
Guérin has also been reported [14].
In children, the most common etiology is viral, with entero-
virus and adenovirus being most commonly associated [15, 16].
Reported causes of noninfectious epididymitis include trauma,
postprostatic biopsy and postvasectomy epididymal inflammation,
sarcoidosis, Behçet disease, vasculitis associated with Henoch-
Schönlein purpura, and medications such as amiodarone [17–21].
DIAGNOSIS OF EPIDIDYMITIS
Physical Examination
The epididymis is located posterior and lateral to the testicle
within the scrotum. In patients with classic findings, upon palpa-
tion of the scrotum, there is a tender and swollen epididymis.
Pain upon palpation of the testicle will also be found if the infec-
tion has progressed to epididymo-orchitis. Scrotal swelling and
erythema may also be present, as well as discharge in men with
urethritis and epididymitis due to sexually transmitted organ-
isms. Prehn sign, relief of pain with elevation of the scrotum, may
also be a sign of epididymitis, but this finding is not consistent or
Epididymitis • CID 2015:61 (Suppl 8) • S771
 reliable [6, 7]. This maneuver increases the pain associated with epididymis, suggest epididymitis. A normal testicle with a
torsion. The position of the testicle in the scrotum also represents marked decrease in blood flow or Doppler wave pulsations is
a diagnostic clue. The testicle is usually in its normal position consistent with a diagnosis of testicular torsion [1]. Surgical ex-
with epididymitis, but is often transverse and high-riding with ploration of an acute scrotum, however, should never be delayed
testicular torsion [22]. Ipsilateral elevation of the testicle due to while waiting for a diagnostic test or procedure.
cremasteric muscle contraction, the cremasteric reflex, is almost
always absent in torsion but present in epididymitis [23]. Patients
TREATMENT OF EPIDIDYMITIS
can also have tender and swollen inguinal lymphadenopathy. The
presence of costovertebral tenderness or suprapubic pain might Both US and European guidelines for the diagnosis and man-
be indicative of pyelonephritis or cystitis when urinary tract agement of epididymitis are published [28–30]. Unfortunately,
coliforms are the etiology. a lack of adherence to and acceptance of these guidelines has
been demonstrated [31, 32]. Drury et al demonstrated that
Diagnostic Testing
<50% of men aged 18–35 years received appropriate treatment
In conjunction with the history and physical exam, diagnostic according to recommended guidelines [32]. These publications
testing will assist in the confirmation of epididymitis and in highlight the fact that dissemination of guidelines is just as im-
detection of the responsible organism or process. In men >35 portant as guideline development and must be improved upon.
years of age and in non–sexually active boys and adolescents, Empiric therapy is indicated before laboratory test results are
a midstream urine should be examined by urinalysis, microsco- available. The goals of treatment of acute epididymitis caused by
py, and urine culture [5]. The same is true for men who have C. trachomatis or N. gonorrhoeae are (1) microbiologic cure of
undergone urinary tract instrumentation or biopsy, and men infection, (2) improvement of signs and symptoms, (3) prevention
who practice insertive anal intercourse. of transmission to others, and (4) a decrease in potential compli-
For sexually active men <35 years of age, evaluation with a cations (eg, infertility or chronic pain). As an adjunct to therapy,
Gram stain or methylene blue/gentian violet stain of urethral se- bed rest, scrotal elevation, and nonsteroidal anti-inflammatory
cretions should be performed to demonstrate the presence of ure- drugs are recommended until fever and local inflammation
thritis. The methylene blue/gentian violet stain is a simple and have subsided. Because therapy is often initiated before labora-
quick, 2-step stain used to evaluate urethral smears [24]. Both tory tests are available, empiric therapy is based on risk factors
of these stains will determine the number of white blood cells and predisposing conditions (Table 1). It should be noted, how-
(WBCs) per oil immersion field and the presence of intracellular ever that complete resolution of discomfort may take weeks after
diplococci. Traditionally, the diagnostic criterion for urethritis the antibiotic regimen is completed.
has been ≥5 WBCs per oil immersion field, but Rietmeijer and
Mettenbrink have recently recommended lowering this number
to ≥2 WBCs per oil immersion field [25]. The authors propose PATIENT FOLLOW-UP AND MANAGEMENT OF
that the current Gram stain criteria for urethritis may be too strin- PARTNERS
gent, as they were developed prior to the era of nucleic acid am-
plification tests (NAATs). In this study, 13 520 Gram stains were Patients should be instructed to return to their healthcare provid-
reviewed. A statistically significant increase in C. trachomatis pos- ers if their symptoms fail to improve within 48 hours of the
itivity, from 6.5% to 16.2%, was observed between the 1 and 2
WBCs per oil immersion field strata. These data support lowering Table 1. Recommended Antibiotic Regimens for Epididymitis
of the urethral smear diagnostic criteria to ≥2 WBCs per oil
immersion field. In clinical settings without urethral smear capa- Recommended Antibiotic
Risk Factors Regimena
bility, a positive leukocyte esterase test on first-void urine or mi-
Risk of sexually transmitted Ceftriaxone 250 mg
croscopic examination of first-void urine sediment demonstrating
infections, particularly gonorrhea intramuscularly plus
≥10 WBCs per high-power field can be performed. and chlamydia doxycycline 100 mg orally
All sexually active men should have a NAAT for the detection twice daily for 10 d
Recent prostate biopsy, vasectomy Levofloxacin 500 mg orally
of gonorrhea and/or chlamydia infection. These tests are highly
or urinary tract instrumentation, or once daily for 10 d or
sensitive and can be performed on urethral swab and first-catch procedures associated with enteric ofloxacin 300 mg orally
urine specimens in the evaluation of men with epididymitis. organisms once daily for 10 d
Risk for both sexually transmitted Ceftriaxone and levofloxacin
Color Doppler ultrasonography is also useful in the diagnosis
and enteric organisms (eg, men or ofloxacin in the above
of epididymitis and can assess both the anatomy of the scrotum who report insertive anal dosages
and perfusion of the testis [26, 27]. Increased blood flow or in- intercourse)

creased Doppler wave pulsations, with an enlarged, thickened a

Ciprofloxacin is ineffective and is not recommended.

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 initiation of treatment. Signs and symptoms of epididymitis that
do not subside within 3 days require reevaluation of the diagnosis
and therapy. Swelling and tenderness that persist after completion
of antimicrobial therapy should be evaluated comprehensively.
The differential diagnosis includes tumor, abscess, infarction,
testicular cancer, tuberculosis, and fungal epididymitis.
Patients who have acute epididymitis that is confirmed or sus-
pected of being caused by N. gonorrhoeae or C. trachomatis
should be instructed to refer sex partners for evaluation and treat-
ment if their contact with the index patient was within the 60 days
preceding onset of their own symptoms. Instructions should also
be given to abstain from sexual intercourse until therapy is com-
pleted and the patient and partners no longer have symptoms.
Notes
Supplement sponsorship. This article appears as part of the supplement
“Evidence Papers for the CDC Sexually Transmitted Diseases Treatment
Guidelines,” sponsored by the Centers for Disease Control and Prevention.
Potential conflict of interest. Author certifies no potential conflicts of
interest.
The author has submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the con-
tent of the manuscript have been disclosed.
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