Epididymitis

Disease Description (Causes and Symptoms)

• Definition summary: Inflammation of the epididymis (the organ behind the testis where sperm are stored and mature), usually caused by an ascending infection from the urethra, prostate, or other sites.
• Causes and pathophysiology
  • Common pathogens vary according to age and sexual history: in sexually active young adults (<35–40 years), sexually transmitted pathogens such as Chlamydia and Neisseria gonorrhoeae are common (with a higher proportion of Chlamydia), while in those before puberty or aged 35 years or older, intestinal bacteria such as Escherichia coli are more common. Other possible causes include Pseudomonas aeruginosa and Mycobacterium tuberculosis.
  • Occurs through an ascending infection from the urethra via the vas deferens, reflux of urine into the urethra, urethral instrumentation (such as catheter insertion), or spread of prostatitis.
• Main symptoms
  • Acute pain, swelling, and tenderness on one side of the scrotum (epididymis)
  • High fever and chills; groin or back pain may also occur
  • Painful urination, increased urinary frequency, and urethral discharge
  • If it becomes chronic, a firm lump in the scrotum and chronic pain
• Diagnostic clues
  • Blood tests: leukocytosis and elevated inflammatory markers
  • Urinalysis and culture: pyuria, bacteriuria, or a positive NAAT (for Chlamydia/Neisseria gonorrhoeae)
  • Scrotal ultrasound (Doppler): increased blood flow compared with the testis (epididymitis); helps distinguish it from testicular torsion (torsion tends to cause decreased blood flow)
  • Prehn sign: pain relief when the scrotum is elevated (epididymitis); testicular torsion tends to worsen

Treatment Methods

• Antibiotic treatment (principles)
  • Sexually active young adults (high likelihood of a sexually transmitted infection): clinically cover Neisseria gonorrhoeae and Chlamydia
    • Example: a single dose of ceftriaxone IM (the recommended dose is 500 mg or 1 g depending on body weight) + doxycycline 100 mg PO twice daily for 10 days.
  • Suspected intestinal bacteria (such as Escherichia coli) (age ≥35 years, history of urinary tract infection, etc.): cover aerobic gram-negative bacteria
    • Example: ofloxacin 300 mg PO twice daily or levofloxacin 500 mg PO once daily, usually for 10 days (10–14 days depending on clinical severity).
  • Severe systemic symptoms (high fever or signs of sepsis) or poor response to treatment: hospital admission and intravenous (IV) antibiotics (initially broad-spectrum), followed by a switch according to susceptibility.
• Supportive treatment
  • Rest (bed rest), scrotal elevation (scrotal support), and application of cold wet compresses
  • Control of pain and inflammation with analgesics/anti-inflammatory drugs (NSAIDs)
  • Drainage (surgical treatment) is required if high fever or an abscess develops
• Chronic or recurrent cases
  • Long-term antibiotic therapy may be used; if pain persists, epididymectomy (removal of the epididymis) may be considered
• Precautions, risk of complications, and self-care
  • Because transmission through sexual contact may occur, sexual partners need testing and treatment
  • Symptoms usually begin to improve within 48 hours after treatment, with complete recovery expected within several days to 2 weeks. Reassessment is needed if there is no response to treatment or symptoms worsen.
  • Delayed treatment may lead to complications such as an epididymal abscess, orchitis (epididymo-orchitis), or obstructive azoospermia (infertility) caused by scarring
  • When taking antibiotics, complete the course as prescribed; report allergies or side effects (such as gastrointestinal symptoms or photosensitivity) immediately
  • Do not resume sexual activity until instructed by a doctor (usually after a specified period following the start of antibiotics and completion of partner treatment)

Checklist Before an Outpatient Visit (Items to Bring and Example Questions)

• Items to bring
  • A list of currently used medications (prescription drugs, OTC medications, and supplements) and any medication allergies
  • The time of symptom onset and progression (when it began, pain severity, and whether there has been fever)
  • Urinary symptoms (increased frequency, burning, hematuria) and whether there is urethral discharge
  • Recent sexual history and condom use, and any previous history of STIs (sexually transmitted infections)
  • Previous test results (such as urinalysis or ultrasound results) or hospitalization records, if available
  • Any history of urologic surgery or procedures (such as catheter insertion)
• Information useful to tell the doctor during the outpatient visit
  • Location of the pain (one side/both sides), nature of the pain (a cutting sensation or dull pain), and factors that worsen or relieve it
  • Whether there has been fever or chills and the highest temperature
  • Whether similar symptoms have occurred in the past (recurrence)
• Examples of medical history questions (items that can be helpful for the patient to record in advance)
  • "The date and time when the symptoms began"
  • "Sexual contact within the past month (whether there was a new partner)"
  • "Whether there have recently been urinary tract procedures or catheter insertion"

Examples of General Questions to Ask the Doctor

• What are the expected side effects and precautions for this medication?
• Which tests (urine culture, NAAT, ultrasound) should be performed, and by when?
• How long should I take the antibiotics? Can I stop taking them when my symptoms improve?
• When can I resume sexual intercourse? Does my partner also need testing and treatment?
• What lifestyle precautions can help prevent recurrence?

Examples of Disease-Specific Questions

• I am 28 years old and recently have a new sexual partner. Which tests must I undergo, and which antibiotics are recommended?
• If the pain does not improve within 48 hours, what measures are needed as the next step (hospitalization, intravenous treatment, drainage, etc.)?

(Emergency: Sudden severe scrotal pain, nausea or vomiting accompanying the pain, or rapidly worsening pain may indicate testicular torsion; immediate evaluation at an emergency department is recommended.)