Acute epididymitis is inflammation of the epididymis causing pain and swelling that develops over the course of a few days and lasts <6 weeks. It is usually unilateral.
In sexually active men, epididymitis is most commonly caused by sexually transmitted organisms including Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium.
In older men, the causative organisms are often 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, and urine specimens for nucleic acid amplification tests for C trachomatis, N gonorrhoeae, and M genitalium (where available). Urine microscopy and culture is also indicated if urinary pathogens are suspected.
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, N gonorrhoeae, or M genitalium are the confirmed or suspected pathogens, evaluation and treatment of the patients’ sexual partner(s) is essential to prevent re-infection and ongoing transmission.
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, 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.
History and exam
Key diagnostic factors
- presence of risk factors
- age >19 years
- unilateral scrotal pain and swelling of gradual onset
- symptoms <6 weeks' duration
- hot, erythematous, swollen hemiscrotum
- frequent and painful micturition
- purulent urethral discharge
Other diagnostic factors
- fluctuant swelling or induration of scrotal tissue
- enlarged or tender prostate
- unprotected sexual intercourse
- bladder outflow obstruction
- instrumentation of urinary tract
- exposure to tuberculosis (TB)
1st investigations to order
- Gram stain of urethral secretions
- urine dipstick test
- urine microscopy
- urine culture
- nucleic acid amplification test (NAAT) of urethral secretions or first-void urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium
- culture of urethral secretions
Investigations to consider
- colour duplex ultrasonography
- surgical exploration
- 3 early morning urine samples for acid-fast bacilli staining, culture, and nucleic acid amplification test for Mycobacterium tuberculosis
- HIV test
- syphilis test
idiopathic or viral
Ameeta E. Singh, BMBS(UK), MSc, FRCPC, FIDSA
Division of Infectious Diseases
University of Alberta
AES declares that she has no competing interests.
Dr Ameeta E. Singh would like to gratefully acknowledge Dr Hossein Sadeghi-Nejad, Dr Lorenzo DiGiorgio, Dr Mary Garthwaite, and Dr Ian Eardley, previous contributors to this topic.
HSN, LDG, and MG declare that they have no competing interests. IE is a consultant to Pfizer, Lilly, and Sanofi. He is a speaker for Lilly.
Sheldon Morris, MD, MPH
Division of Infectious Diseases
Department of Medicine
UCSD Antiviral Research Center
Division of Family Medicine
Department of Family and Preventive Medicine
UCSD La Jolla Family and Sports Medicine
SM has received research funding support from NIH CHRP, CIRM, and Gilead Sciences. He has financial interests in Impact Biomedicines (now Celgene) and Forty Seven Inc. There is no conflict between these financial interests and any content in this topic.
Altaf Mangera, MBChB (Hons), MD, FRCS (Urol), FEBU
Department of Urology
Royal Hallamshire Hospital
AM declares that he has no competing interests.
- Testicular torsion
- Acute idiopathic scrotal oedema
- Infected hydrocele
- ACR appropriateness criteria: acute onset of scrotal pain - without trauma, without antecedent mass
- Sexual and reproductive health
GonorrhoeaMore Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer