Epididymitis is the most common cause of intrascrotal inflammation,

5
and retrograde ascent of pathogens is the usual route of infection. Although epididymitis was historically thought to be
caused by chemical irritation from urine reflux, a study published in 1979 showed that bacteria were responsible for most cases.
6
The study also showed that the type of bacteria varied with
patient age.
In men 14 to 35 years of age, epididymitis is most commonly caused by sexually transmitted Neisseria gonorrhoeae or Chlamydia trachomatis infection.
7,8
Nonspecific bacterial epididymitis is
caused by various aerobic bacteria and is often associated with anatomic abnormalities. In those younger than 14 years or older than 35 years, epididymitis is generally caused by infection with
common urinary tract pathogens, such as Escherichia coli. In men who practice insertive anal intercourse, coliform bacteria (e.g., E. coli) are common causative pathogens,
although Haemophilus influenzae infection has also been linked. Other pathogens that are less commonly associated with epididymitis includeUreaplasma urealyticum, Proteus mirabilis,
Klebsiella pneumoniae, and Pseudomonas aeruginosa. Epididymitis secondary to Mycobacterium tuberculosis infection is rare but must be considered among those at high risk. In patients with
human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome, fungal and viral etiologies, including cytomegalovirus, have been reported.
7,8

Noninfectious etiologies of epididymitis have been identified in numerous groups. One study found that the annual incidence of epididymitis in boys two to 13 years of age is 1.2 per 1,000, and
that the condition in this age group is primarily a postinfectious inflammatory reaction to pathogens (e.g.,Mycoplasma pneumoniae, enteroviruses, adenoviruses) that follows a benign
course.
9
Other noninfectious causes of epididymitis include vasculitides and certain medications, such as amiodarone (Cardarone).
10

Risk factors for epididymitis in all men include sexual activity, strenuous physical activity, bicycle or motorcycle riding, and prolonged periods of sitting (e.g., during travel, with a sedentary
job).
1,3,4
Risk factors in men older than 35 years and in prepubertal boys include recent urinary tract surgery or instrumentation and anatomic abnormalities, such as prostatic obstruction in older
men and posterior urethral valves or meatal stenosis in prepubertal boys.
1,2,4,5

With the exception of viral diseases, genitourinary tract infections seldom primarily involve the testis. Orchitis usually occurs in patients with concurrent epididymitis, and the causative
pathogens of the conditions are similar. Blood-borne dissemination is the major route of isolated testicular infection. Mumps is the most common cause of viral orchitis (orchitis occurs in 20 to
30 percent of men with mumps infection).
11
Pyogenic orchitis usually is caused by an inflammatory process in the epididymis.
Diagnosis
HISTORY AND PHYSICAL EXAMINATION
When evaluating patients with acute testicular or scrotal pain and swelling (acute scrotum), there should be a high index of suspicion for testicular torsion. In fact, testicular torsion is most
commonly misdiagnosed as epididymitis. Any patient with acute scrotum and any patient in whom testicular torsion is otherwise suspected should receive urgent referral to a urologist for
possible surgery.
12
Table 1 presents the selected differential diagnosis of acute scrotum.
1315

Table 1 Selected Differential Diagnosis of Acute Scrotum
View Table
Patients with epididymitis usually present with gradual onset of pain that is localized posterior to the testis and that occasionally radiates to the lower abdomen. Although patients often have
unilateral pain that begins in the epididymis, the pain can spread to the adjacent testis. Symptoms of lower urinary tract infection, such as fever, frequency, urgency, hematuria, and dysuria,
may be present. These symptoms are common with epididymitis and orchitis but are rare with testicular torsion. Recurrent pain is rare with epididymitis and torsion of the appendix testis (upper
pole of testis), but can occur with testicular torsion (caused by intermittent torsion with spontaneous resolution).
16
The presence or absence of nausea and vomiting is not helpful in
differentiating between epididymitis or orchitis and testicular torsion because it may occur with any of the conditions. Viral orchitis is associated with the abrupt onset of scrotal pain and swelling
and is primarily unilateral. When associated with mumps infection, orchitis generally appears four to seven days after the development of parotitis.
Although testicular torsion can occur at any age, the incidence is highest between 12 and 18 years, followed by the neonatal period. Torsion is rare in those older than 35 years and, with the
exception of the neonatal period, in those younger than eight years. Torsion of the appendix testis usually occurs between seven and 14 years of age and is rare in those older than 20 years.
Patients with epididymitis and orchitis often have tachycardia or fever. Patients may also be uncomfortable while seated, but this is also common with testicular torsion. It is important to check
for costovertebral angle tenderness, a sign of concomitant pyelonephritis, and for signs of cystitis by palpating the suprapubic region. The inguinal area should be examined for a hernia or for
swollen and tender lymph nodes, which are suggestive of the inflammatory or infectious process of epididymitis and orchitis. The scrotum should be examined for a tender spermatic cord,
which is suggestive of epididymitis.
A high-riding, transversely oriented testis is common with testicular torsion,
17
whereas the testis is usually in its normal anatomic location with epididymitis and orchitis. Early testicular swelling
and tenderness that progress to a reactive hydrocele and scrotal wall erythema is common with testicular torsion. With epididymitis, the epididymis (located posterolateral to the testis) is tender
and swollen and often indurated. In later stages, this may progress to testicular swelling (orchitis) with a reactive hydrocele and scrotal wall erythema that mimic testicular torsion. Scrotal
swelling also occurs with indirect inguinal hernias, and bowel sounds may be auscultated in the scrotum.
With torsion of the appendix testis, a reactive hydrocele is often present and tenderness is correlated with the anatomic position of the appendix testis. The blue dot sign, a bluish discoloration
in the area of the appendix testis, may be present on the scrotal wall, indicating infarction and necrosis. The cremasteric reflex, elicited by stroking the skin of the upper medial thigh, should
always be evaluated. A normal reflex (i.e., ipsilateral cremasteric muscle contraction producing unilateral testis elevation) is present with epididymitis or orchitis and torsion of the appendix
testis, but is almost always absent with testicular torsion.
4,18,19
Prehn sign, the relief of pain with the elevation of the testis, may be elicited in patients with epididymitis, although this is not a
reliable finding.
18,20
Elevation of the testis usually exacerbates the pain of testicular torsion.
A complication from a urine infection
Germs (bacteria) such as E. coli that cause urine infections can sometimes track down the vas deferens to cause an epididymo-orchitis. This can happen at any age and is the most common
cause of epididymo-orchitis in men aged over 35. This is because partial blockage of urine flow becomes more common with increasing age, due an enlarged prostate or narrowing of the
urethra (urethral stricture). The urethra is the tube that urine flows out of from the bladder. Partial blockage of urine makes you more prone to develop urine infections. A complication of a urine
infection is also the usual cause of epididymo-orchitis in young boys.
Sexually transmitted infection
This is the most common cause of epididymo-orchitis in young men (but can occur in any sexually active man). It most commonly occurs with chlamydial and gonorrhoeal infections. In men,
these infections typically infect the urethra to cause a urethritis. However, sometimes the infection can track down the vas deferens to the epididymis and testis.
Related blogsQ
Sexual health
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The mumps virus
The mumps virus used to be a common cause. Most people with mumps develop swelling of the parotid salivary glands. However, mumps in boys also causes epididymo-orchitis in about 1 in 5
cases. The virus gets to the testes via the bloodstream. This cause is now uncommon since the measles, mumps and rubella (MMR) immunisation is now routinely given to children.
An operation to the prostate or urethra
This may allow germs (bacteria) into the urethra which may track down to the testes. Epididymo-orchitis used to be a common complication after removal of the prostate (prostatectomy). This is
now rare due to better surgical techniques.
Medication
Epididymo-orchitis can occasionally be a side-effect of a medicine called amiodarone. It normally occurs at doses above 200 mg.
Uncommon causes
Other viral infections are uncommon causes of epididymo-orchitis. Infection from other parts of the body can, rarely, travel in the blood to the testes, such as tuberculosis (TB) and brucellosis.
When this happens it is usually in people who have a problem with their immune system (for example, people with AIDS). Schist osomiasis is a tropical infectious disease that can cause
epididymo-orchitis. Men with Behet's disease may develop inflamed testes to cause a non-infective epididymo-orchitis. Injury to the scrotum can cause inflammation of the epididymis and
testis.
A complication from a urine infection
Germs (bacteria) such as E. coli that cause urine infections can sometimes track down the vas deferens to cause an epididymo-orchitis. This can happen at any age and is the most common
cause of epididymo-orchitis in men aged over 35. This is because partial blockage of urine flow becomes more common with increasing age, due an enlarged prostate or narrowing of the
urethra (urethral stricture). The urethra is the tube that urine flows out of from the bladder. Partial blockage of urine makes you more prone to develop urine infections. A complication of a urine
infection is also the usual cause of epididymo-orchitis in young boys.
Sexually transmitted infection
This is the most common cause of epididymo-orchitis in young men (but can occur in any sexually active man). It most commonly occurs with chlamydial and gonorrhoeal infections. In men,
these infections typically infect the urethra to cause a urethritis. However, sometimes the infection can track down the vas deferens to the epididymis and testis.
Related blogsQ
Sexual health
Teenage health - it's a jungle out there
The mumps virus
The mumps virus used to be a common cause. Most people with mumps develop swelling of the parotid salivary glands. However, mumps in boys also causes epididymo-orchitis in about 1 in 5
cases. The virus gets to the testes via the bloodstream. This cause is now uncommon since the measles, mumps and rubella (MMR) immunisation is now routinely given to children.
An operation to the prostate or urethra
This may allow germs (bacteria) into the urethra which may track down to the testes. Epididymo-orchitis used to be a common complication after removal of the prostate (prostatectomy). This is
now rare due to better surgical techniques.
Medication
Epididymo-orchitis can occasionally be a side-effect of a medicine called amiodarone. It normally occurs at doses above 200 mg.
Uncommon causes
Other viral infections are uncommon causes of epididymo-orchitis. Infection from other parts of the body can, rarely, travel in the blood to the testes, such as tuberculosis (TB) and brucel losis.
When this happens it is usually in people who have a problem with their immune system (for example, people with AIDS). Schistosomiasis is a tropical infectious disease that can cause
epididymo-orchitis. Men with Behet's disease may develop inflamed testes to cause a non-infective epididymo-orchitis. Injury to the scrotum can cause inflammation of the epididymis and
testis.
A complication from a urine infection
Germs (bacteria) such as E. coli that cause urine infections can sometimes track down the vas
deferens to cause an epididymo-orchitis. This can happen at any age and is the most common
cause of epididymo-orchitis in men aged over 35. This is because partial blockage of urine flow
becomes more common with increasing age, due an enlarged prostate or narrowing of the urethra
(urethral stricture). The urethra is the tube that urine flows out of from the bladder. Partial blockage
of urine makes you more prone to develop urine infections. A complication of a urine infection is also
the usual cause of epididymo-orchitis in young boys.
Sexually transmitted infection
This is the most common cause of epididymo-orchitis in young men (but can occur in any sexually
active man). It most commonly occurs with chlamydial and gonorrhoeal infections. In men, these
infections typically infect the urethra to cause a urethritis. However, sometimes the infection can
track down the vas deferens to the epididymis and testis.
Related blogsQ
Sexual health
Teenage health - it's a jungle out there
The mumps virus
The mumps virus used to be a common cause. Most people with mumps develop swelling of the
parotid salivary glands. However, mumps in boys also causes epididymo-orchitis in about 1 in 5
cases. The virus gets to the testes via the bloodstream. This cause is now uncommon since the
measles, mumps and rubella (MMR) immunisation is now routinely given to children.
An operation to the prostate or urethra
This may allow germs (bacteria) into the urethra which may track down to the testes. Epididymo-
orchitis used to be a common complication after removal of the prostate (prostatectomy). This is now
rare due to better surgical techniques.
Medication
Epididymo-orchitis can occasionally be a side-effect of a medicine called amiodarone. It normally
occurs at doses above 200 mg.
Uncommon causes
Other viral infections are uncommon causes of epididymo-orchitis. Infection from other parts of the
body can, rarely, travel in the blood to the testes, such as tuberculosis (TB) and brucellosis. When
this happens it is usually in people who have a problem with their immune system (for example,
people with AIDS). Schistosomiasis is a tropical infectious disease that can cause epididymo-
orchitis. Men with Behet's disease may develop inflamed testes to cause a non-infective epididymo-
orchitis. Injury to the scrotum can cause inflammation of the epididymis and testis.
A complication from a urine infection
Germs (bacteria) such as E. coli that cause urine infections can sometimes track down the vas
deferens to cause an epididymo-orchitis. This can happen at any age and is the most common
cause of epididymo-orchitis in men aged over 35. This is because partial blockage of urine flow
becomes more common with increasing age, due an enlarged prostate or narrowing of the urethra
(urethral stricture). The urethra is the tube that urine flows out of from the bladder. Partial blockage
of urine makes you more prone to develop urine infections. A complication of a urine infection is also
the usual cause of epididymo-orchitis in young boys.
Sexually transmitted infection
This is the most common cause of epididymo-orchitis in young men (but can occur in any sexually
active man). It most commonly occurs with chlamydial and gonorrhoeal infections. In men, these
infections typically infect the urethra to cause a urethritis. However, sometimes the infection can
track down the vas deferens to the epididymis and testis.
Related blogsQ
Sexual health
Teenage health - it's a jungle out there
The mumps virus
The mumps virus used to be a common cause. Most people with mumps develop swelling of the
parotid salivary glands. However, mumps in boys also causes epididymo-orchitis in about 1 in 5
cases. The virus gets to the testes via the bloodstream. This cause is now uncommon since the
measles, mumps and rubella (MMR) immunisation is now routinely given to children.
An operation to the prostate or urethra
This may allow germs (bacteria) into the urethra which may track down to the testes. Epididymo-
orchitis used to be a common complication after removal of the prostate (prostatectomy). This is now
rare due to better surgical techniques.
Medication
Epididymo-orchitis can occasionally be a side-effect of a medicine called amiodarone. It normally
occurs at doses above 200 mg.
Uncommon causes
Other viral infections are uncommon causes of epididymo-orchitis. Infection from other parts of the
body can, rarely, travel in the blood to the testes, such as tuberculosis (TB) and brucellosis. When
this happens it is usually in people who have a problem with their immune system (for example,
people with AIDS). Schistosomiasis is a tropical infectious disease that can cause epididymo-
orchitis. Men with Behet's disease may develop inflamed testes to cause a non-infective epididymo-
orchitis. Injury to the scrotum can cause inflammation of the epididymis and testis.
Acute epididymitis is usually caused by a bacterial infection. In children who haven't reached puberty, the infection usually starts in the bladder or kidney and then spreads to the testicle.
This is often associated with a birth-related abnormality that predisposes to urinary tract infection. In sexually active men, the most common infection causing epididymitis is a sexually
transmitted disease such as gonorrhea or Chlamydia infection. These infections start in the urethra, causing urethritis, which can then move into the testicle. In men over 40 years of
age, the most common cause is bacteria from the urinary tract. Other causes can include: bladder outlet obstruction due to enlargement of the prostate; partial blockage of the urethra;
bacterial prostatitis (an infection of the prostate gland) or recent catheterization of the urethra. In any of these cases, the original infection may not cause symptoms, and the first sign of
a problem may be epididymitis. Bacterial epididymitis rarely occurs when a bacterial infection spreads from the bloodstream into the epididymis, although this is the typical way that
tuberculosis infection can involve the epididymis. Epididymitis is occasionally due to causes other than infection. Chemical epididymitis occurs when sterile urine flows backward from
the urethra to the epididymis, which most commonly occurs with heavy lifting or straining. The urine causes inflammation without infection. The drug amiodarone also can cause a non-
infectious epididymitis, and there are other cases of non-infectious epididymitis without known cause.
Chronic epididymitis may develop after several episodes of acute epididymitis that do not subside, but also can occur without any symptomatic episodes of acute epididymitis or prior
infectionin which case the cause is unknown.
In most cases of acute orchitis, the testicle is inflamed due to the spread of a bacterial infection from the epididymis, and therefore "epididymo-orchitits" is the correct term. Although
orchitis without epididymitis can occur from a bacterial infection, orchitis without epididymitis usually results from an infection related to the mumps virus (or other virus infections).
"Mumps orchitis" occurs in approximately one-third of males who contract mumps after puberty.
Acute epididymo-orchitis is usually a primary bacterial or rarely a tuberculous infection of the epididymis that has spread to the testicle to involve both structures. Rarely, it can start in
the testicle and spread to the epididymis. Mumps orchitis does not spread to the epididymis.
What are the symptoms and how are they diagnosed?
Acute epididymitis and acute epididymo-orchitis: Symptoms occur not only from the local infection, but also from the original source of the infection. Common symptoms from the
original source of the infection include: urethral discharge and urethral pain or itching (from urethritis); pelvic pain and urinary frequency, urgency or painful/burning urination (from
infection of the bladder, called cystitis); fever, perineal pain, urinary frequency, urinary urgency or painful/burning urination (from infection of the prostate, called prostatitis); fever
and flankpain (from infection of the kidney, called pyelonephritis). In some cases, pain in the scrotum from the local infection is the only noticeable symptom. The pain starts at the back of
one testicle but can soon spread to the entire testicle, the scrotum and occasionally the groin. Swelling, tenderness, redness, firmness and warmth of the skin may also accompany the
pain. The entire scrotum can swell up with fluid (hydrocele). To make the diagnosis, the doctor will ask you about your medical history and examine you. The doctor may test a urine
sample and look at it under the microscope to assess for bacterial infection, culture a urine sample as a more definitive way to see if there is bacterial infection, or examine a swab
obtained from the urethra (if urethritis is suggested by your symptoms). If your pain came on very suddenly and severely, then an ultrasound, which is a non-invasive test that uses
sound waves to look at the epididymis and measure blood flow, might be used to distinguish epididymitis from another condition called testicular torsion. This is managed very differently
than epididymitis, so making the distinction is very important. Tuberculous epididymitis presents in the same way, although chemical and amiodarone epididymitis are less severe.
Chronic epididymitis: The pain occurs only in the scrotal contents, and is less severe and more localized than acute epididymitis. Swelling, tenderness, redness and warmth of the skin
do not occur. Additional tests may be used as for acute epididymitis, but are less frequently required. In acute epididymitis the urine is usually infected, whereas in chronic epididymitis
it is usually not.
Acute orchitis: During the acute phase of mumps orchitis, symptoms include pain of varying severity, tenderness and swelling. The parotiditis (swelling of facial glands) of mumps
usually precedes orchitis by three to seven days. Isolated orchitis from bacterial infection has the same symptoms of acute epididymitis or epididymo-orchitits.