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What is Epididymitis and how is it treated?

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The epididymis is a crescent shaped structure. It runs down the middle of the back of the testis from top to bottom. It functions to carry the sperm from the testes (where they are produced) to the vas deferens, which is a muscular tube that carries the sperm. The epididymis is more susceptible to infection than the other structures in the scrotum and this infection is called epididymitis. Infections can subsequently lead to scar tissue, which can block the sperm from moving through it and trap it in the testes (or the part of the epididymis before the blockage.) The sperm are still being produced; they are just not able to come through. If this happens on both sides a man may have no sperm in the ejaculate.

What causes epididymitis (the epididymis to get infected)?

In men who are less than 40, most cases of epididymitis are from sexually transmitted diseases. The organisms make their way into the urethra (the tube from which a man urinates and ejaculates) and then work their way backwards into the ejaculatory ducts (the ducts that carry the sperm). The most common organism is chlamydia. In men who are older than forty, the most common organisms to cause epididymitis are "coliform bacteria." Coliform bacteria can actually be found in the genitals of all men, but before the age of 40 these organisms are generally only "colonized" in men's genitals; that is, the bacteria live there but do not cause an infection. However, in older men with larger prostates, there is often more urine left in the bladder at the end of urination. This allows the bacteria to grow. The bacteria can then move backwards through the genital tract and cause an infection of the epididymis.

How do I know if I have epididymitis?

If a man has an "acute" epididymal infection (rapid onset, as opposed to "chronic") he will usually feel intense pain in the scrotum. The pain can radiate into the groin, and even into the flank. The epididymis will get swollen and tender. He may notice that the scrotum has increased in size significantly. If the infection is very severe, the testis may also be involved, tender, and swollen. Sometime, in reaction to the infection fluid will develop around the testis (a "reactive hydrocele.")

Other symptoms may include a fever. Symptoms of urination may also develop. This include burning with urination, urinating frequently small amounts (day and or night), and urgency (having to go to the bathroom immediately.)

The physician will look for an enlarged scrotum. It will be tender and possibly reddened. The structures leading to the testis will also be swollen and tender. There may be some penile discharge.

What else could I have?

Epididymitis is important to diagnose for its own sake. However, even more important is distinguishing it from testicular torsion. This is where the testis twists on itself and cuts off its own blood supply. If this is not diagnosed and reversed within four hours the entire testis may be destroyed. Thus it is very important that if you develop significant testicular pain that you present yourself to your doctor or emergency room immediately.

How is the epididymitis diagnosed?

The first task is to distinguish it from testicular torsion. Once it has been shown to be epididymitis the next step is to figure out what organism is causing it. A urinalysis and urine culture will be sent. Urethral cultures are also sent, as are semen cultures.

How is epididymitis treated?

This will depend on the organism. But antibiotics are the main treatment. Many organisms need to be treated with a full six weeks of antibiotics. If your doctor prescribes antibiotics for you, complete the entire prescription even if you are feeling better in the middle. You may have simply killed the most susceptible organisms and when the antibiotics are stopped, the hardier organisms will come back and be even harder to treat.

It is important that you support the scrotum by wearing either a jock strap or relatively tight underwear. It is also important that you consider taking an anti-inflammatory (always with meals to avoid an ulcer.) These include ibuprofen (Advil, Motrin, Nuprin etc.) and naprosyn among others. Hot baths are also important to promote healing.

What are the potential complications?

If the infection is very severe the entire testes may be infected. If a collection of pus forms (abscess) it may need to be surgically drained. The testis may actually be destroyed by the infection.

Patients may develop chronic epididymitis. This may be a chronic discomfort of varying degrees in the epididymis and scrotum. It may be very hard to treat, though with time it may burn itself out. In severe cases where everything else has been tried, and where fertility is no longer an issue, the epididymis may need to be surgically removed.

The epididymis may scar. It may then be blocked and not allow the sperm to flow through. If this happens on both sides, or affects a solitary testis, there may be no sperm in the ejaculate at all. These patients may benefit from surgery to reverse the blockage (by bypassing it). They may also need to have the sperm taken from the testes or epididymis directly and then injected directly into a woman's eggs (in vitro fertilization with intracytoplasmic sperm injection).

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