Pain in the scrotum or testicles is an alarming symptom that can cause significant anxiety and concern. While several conditions can cause such discomfort, one of the most common culprits is epididymitis. This condition, which involves inflammation of a small but vital structure attached to the testicle, is responsible for over 600,000 medical visits each year in the United States alone. Though often treatable with a straightforward course of antibiotics, ignoring the symptoms can lead to chronic pain and more serious complications. Understanding what epididymitis is, what causes it, and how it is treated is essential for anyone experiencing these symptoms to seek timely and appropriate medical care.

Epididymitis is an inflammation of the epididymis, a tightly coiled tube located at the back of the testicle that stores and carries sperm. This condition can cause significant pain and swelling in the scrotum and may affect one or both sides, although it typically occurs on just one.

The epididymis plays a crucial role in sperm maturation. When it becomes inflamed, it can disrupt normal reproductive function and cause discomfort that ranges from mild to severe. Though more common in men aged 14 to 35, epididymitis can occur at any age.

Analogy: Think of the epididymis like a narrow, winding garden hose that gently carries water (sperm) to the right place. If bacteria get into the system, it’s like dirt or grit clogging the hose causing swelling, pressure, and pain. Just like a garden hose that kinks or gets inflamed with buildup, the epididymis becomes tender and sore when inflamed.

Medical professionals often classify epididymitis into two categories based on duration:

• Acute Epididymitis: This is a sudden onset of symptoms that have been present for less than six weeks. It is the most common form and usually responds well to treatment.
• Chronic Epididymitis: This is defined as discomfort or pain in the epididymis lasting three months or longer. The symptoms are often less severe than in the acute form but can be persistent and have a significant impact on quality of life.

The inflammation seen in epididymitis is almost always the result of a bacterial infection. In most cases, the infection starts elsewhere in the urinary or reproductive tract and travels backward to the epididymis. The specific bacteria responsible often depend heavily on a person’s age and lifestyle.

Younger, Sexually Active Men (Typically Under 35): For men in this age group, epididymitis is most frequently caused by a sexually transmitted infection (STI). The two most common culprits are Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhea). According to the Centers for Disease Control and Prevention, these bacteria can initially infect the urethra (the tube that carries urine out of the body) and then travel in a retrograde (backward) fashion through the reproductive tract up the vas deferens and into the epididymis.

Older Men, Children, and Men Who Are Not Sexually Active: In these populations, epididymitis is usually caused by non-sexually transmitted bacteria that originate in the urinary tract. These are often common intestinal bacteria, with Escherichia coli (E. coli) being the most frequent cause. These bacteria can cause a urinary tract infection (UTI) or bladder infection (cystitis) and then spread backward to the epididymis. Structural problems within the urinary tract that cause abnormal urine flow, such as an enlarged prostate (benign prostatic hyperplasia or BPH) in older men, can increase the risk.

Non-Infectious Causes: While less common, epididymitis can sometimes occur without an infection. These cases include:

• Chemical Epididymitis: This can happen when urine flows backward into the epididymis, often due to heavy lifting, straining, or other activities that increase abdominal pressure. The chemicals in the urine cause irritation and inflammation without the presence of bacteria.
• Trauma: A direct injury to the scrotum can cause inflammation of the epididymis.
• Medication-Induced: Certain medications, most notably the heart medication amiodarone, can cause epididymal inflammation as a side effect.
• Systemic Diseases: Rarely, other diseases like tuberculosis or Behçet’s disease can lead to epididymitis.

Clinically, it’s common to notice that in younger patients, STIs are a leading cause, while in older adults, we often trace it back to urinary or prostate issues.

The specific risk factors that make a person more susceptible to developing this condition, often align with the causes mentioned above and create opportunities for bacteria to enter and travel through the urinary and reproductive tracts.

Key risk factors for developing epididymitis include:

• Sexual Activity: Engaging in sex, particularly with multiple partners and without using condoms, is the primary risk factor for epididymitis caused by STIs. Anal intercourse can also increase the risk of E. coli bacteria from the rectum entering the urethra.
• History of STIs: Having had a prior STI, or if your partner has an STI, significantly increases your risk.
• Urinary Tract Problems: Any condition that affects the normal structure or function of the urinary tract can be a risk factor. This includes a history of UTIs, having a urinary catheter, or undergoing recent surgery on the bladder or prostate.
• Enlarged Prostate (BPH): In older men, an enlarged prostate can prevent the bladder from emptying completely. The stagnant urine can become a breeding ground for bacteria, increasing the risk of UTIs that can spread to the epididymis.
• Anatomical Abnormalities: Being uncircumcised or having a structural defect in the urinary tract can increase susceptibility.
• Heavy Physical Exertion: As mentioned, straining or lifting very heavy objects can cause a backflow of urine into the epididymis, leading to chemical inflammation.

Symptoms of acute epididymitis usually develop over one to three days. A key feature is that the pain typically starts gradually and builds, which helps doctors distinguish it from testicular torsion, a surgical emergency characterized by a very sudden and severe onset of pain.

The most common signs and symptoms include:

• Scrotal Pain and Tenderness: This is the hallmark symptom, usually localized to one side and beginning at the back of the testicle before spreading.
• Swelling and Redness: The scrotum on the affected side often becomes swollen, warm to the touch, and red. A tender lump may be felt on the back of the testicle.
• Pain During Urination (Dysuria): A burning or stinging sensation while urinating is common, especially if the infection started in the urethra.
• Fever and Chills: The body’s systemic response to infection can cause a low-grade fever and chills.
• Urethral Discharge: A discharge from the tip of the penis may be present, particularly if the cause is STIs like gonorrhea or chlamydia.
• Pain in the Lower Abdomen or Pelvic Area: The pain can sometimes radiate to the flank or lower abdomen.
• Pain during Intercourse or Ejaculation: Inflammation in the reproductive tract can make sexual activity painful.

The diagnostic process is focused on identifying the cause of the inflammation and, most importantly, ruling out more urgent conditions like testicular torsion.

Diagnosis

A typical evaluation will include:

1. Medical History and Physical Exam: Your doctor will ask about your symptoms, sexual history, and any previous urinary issues. The physical exam will involve a careful examination of the scrotum, testicles, and abdomen to pinpoint the location of the swelling and tenderness.
2. Lab Tests: Urine tests (urinalysis and culture) and swabs from the urethra are taken to test for bacteria and STIs. Blood tests may be done to look for signs of infection.
3. Scrotal Ultrasound: An ultrasound with Doppler imaging is a very common and important test. It uses sound waves to create images of the testicles and epididymis. The Doppler component can measure blood flow. This test is excellent for confirming epididymitis (it will show increased blood flow to the inflamed structure) and for definitively ruling out testicular torsion (which is characterized by a lack of blood flow).

Treatment

The goal of treatment is to cure the infection, relieve symptoms and prevent complications.

• Antibiotics: This is the cornerstone of treatment for bacterial epididymitis. The type of antibiotic prescribed depends on the likely cause. For younger, sexually active men, doctors will prescribe medications that cover chlamydia and gonorrhea. For older men, the antibiotics will target common urinary tract bacteria like E. coli. In my experience, most patients respond well to antibiotics within a few days, especially when they start treatment early.
• Symptom Management: To manage the pain and swelling, your doctor will recommend rest, scrotal elevation (lying down and placing a rolled towel under the scrotum), and applying cold packs to the area. Over-the-counter painkillers like ibuprofen or naproxen can help reduce both pain and inflammation. Wearing an athletic supporter to provide scrotal support can also increase comfort.
• Follow-up: A follow-up visit with your doctor is important to ensure the infection has cleared and symptoms have resolved. If a partner may have been exposed to an STI, they must also be notified and treated.

Prevention

While not all cases of epididymitis can be prevented, you can take several steps to lower your risk:

• Practice Safe Sex: Consistently using condoms is the most effective way to prevent STIs that cause epididymitis.
• Get Screened for STIs: If you are sexually active, regular STI screening is important for you and your partners.
• Manage Underlying Conditions: For older men, properly managing conditions like BPH can help ensure the bladder empties fully, reducing the risk of UTIs.
• Avoid Straining: Use proper techniques when lifting heavy objects to avoid causing a reflux of urine.

Epididymitis is a common and highly treatable condition, but it should never be taken lightly. The gradual onset of pain, swelling, and redness in the scrotum is a clear signal that something is wrong and requires medical evaluation. A prompt diagnosis is crucial not only to start the right treatment but also to rule out surgical emergencies like testicular torsion. With a course of antibiotics and supportive care, most men recover completely without long-term issues. Remember, testicular pain is never normal. By understanding the signs of epididymitis and seeking help without delay, you can protect your health and well-being.

• Centers for Disease Control and Prevention. (2021). Epididymitis – STI treatment guidelines. Retrieved from https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
• Mayo Clinic. (2023). Epididymitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/epididymitis/symptoms-causes/syc-20363853
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2019). Epididymitis. Retrieved from https://www.niddk.nih.gov/health-information/urologic-diseases/epididymitis