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Acute epididymitis

Last reviewed: 2 Apr 2025
Last updated: 27 Feb 2025

Summary

Definition

History and exam

Key diagnostic factors

  • age >19 years
  • unilateral scrotal pain and swelling of gradual onset
  • symptoms <6 weeks' duration
  • tenderness
  • hot, erythematous, swollen hemiscrotum
  • frequent and painful micturition
  • purulent urethral discharge
Full details

Other diagnostic factors

  • pyrexia
  • fluctuant swelling or induration of scrotal tissue
  • enlarged or tender prostate
Full details

Risk factors

  • unprotected sexual intercourse
  • bladder outflow obstruction
  • instrumentation of urinary tract
  • immunosuppression
  • vasculitis
  • amiodarone
  • mumps
  • exposure to tuberculosis (TB)
Full details

Diagnostic tests

1st tests 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
Full details

Tests to consider

  • scrotal color duplex ultrasonography
  • surgical exploration
  • 3 early morning urine samples for acid-fast bacilli staining, culture, and NAAT for Mycobacterium tuberculosis
  • HIV test
  • syphilis test
Full details

Treatment algorithm

ACUTE

bacterial infection

amiodarone-induced

underlying vasculitis

idiopathic or viral

tuberculous

Contributors

Authors

Ameeta E. Singh, BMBS(UK), MSc, FRCPC, FIDSA

Clinical Professor

Division of Infectious Diseases

University of Alberta

Edmonton

Canada

Disclosures

AES declares that she has no competing interests.

Acknowledgements

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.

Disclosures

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.

Peer reviewers

Sheldon Morris, MD, MPH

Assistant Professor

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

San Diego

CA

Disclosures

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

Consultant Urologist

Department of Urology

Royal Hallamshire Hospital

Sheffield

UK

Disclosures

AM declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

British Association for Sexual Health and HIV (BASHH). 2019 UK national guideline for the management of epididymo-orchitis. 2019 [internet publication].Full text

American College of Radiology. ACR appropriateness criteria: acute onset of scrotal pain - without trauma, without antecedent mass. 2014 (revised 2018) [internet publication].Full text

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187.Full text  Abstract

Street EJ, Justice ED, Kopa Z, et al. The 2016 European guideline on the management of epididymo-orchitis. Int J STD AIDS. 2017 Jul;28(8):744-9. Abstract

European Association of Urology. Guidelines on urological infections. Mar 2022 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Differentials

    • Testicular torsion
    • Acute idiopathic scrotal edema
    • Infected hydrocele
    More Differentials
  • Guidelines

    • ACR appropriateness criteria: acute onset of scrotal pain - without trauma, without antecedent mass
    • 2021 European guideline on Mycoplasma genitalium infections
    More Guidelines
  • Patient information

    Chlamydia

    Gonorrhea

    More Patient information
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