Epididymitis
The epididymis is a tightly coiled tube several metres long that lies behind the testicle; it is where sperm finish maturing and are stored.
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Medicines commonly prescribed for Epididymitis
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 500 mgActive substance: azithromycinManufacturer: Industria Quimica Y Farmaceutica Vir S.A.Prescription requiredDosage form: TABLET, 250 mgActive substance: azithromycinManufacturer: Teva Pharma S.L.U.Prescription requiredDosage form: TABLET, 500 mg/125 mgActive substance: amoxicillin and beta-lactamase inhibitorManufacturer: Laboratorios Support Pharma S.L.Prescription required
The epididymis is a tightly coiled tube several metres long that lies behind the testicle; it is where sperm finish maturing and are stored. When infection reaches it, it swells and becomes painful. That is epididymitis: an unpleasant condition but, in the great majority of cases, curable with antibiotics — provided it has been told apart from another kind of scrotal pain in which the clock runs in hours.
How it starts and what it feels like
It usually builds up over several hours or a couple of days rather than all at once. First comes a dragging heaviness in one side of the scrotum, then the pain increases, the skin reddens and feels hot, and that side becomes visibly bigger. By this stage the border between testicle and epididymis is already hard to feel, because the inflammation often spreads to the testicle as well.
Alongside this there may be:
- pain low in the abdomen or in the groin on the same side, sometimes arriving before the scrotal pain;
- a temperature and shivering;
- stinging on passing urine and needing to go often;
- discharge from the urethra — clear, white, yellowish or greenish;
- fluid collecting around the testicle, which feels like a soft swelling.
There is a widespread idea that in epididymitis the pain eases when the scrotum is lifted, while in torsion it does not. That sign is unreliable and no decision should rest on it.
Testicular torsion: the first thing to rule out
Torsion is when the testicle twists on the spermatic cord and pinches off its own blood supply. Without blood the tissue dies, and only a few hours are available to save it: within roughly the first six the testicle can usually be preserved, after which the odds fall away quickly. That is why scrotal pain is never watched at home.
Call an ambulance or go straight to the emergency department if any of the following apply:
- the pain came on suddenly, within minutes, and is severe — often at night or after exercise;
- nausea or vomiting has come with the pain;
- the testicle has been drawn up higher than usual or sits sideways;
- severe pain in the scrotum or abdomen in a teenager or a young man;
- an abruptly red, swollen scrotum in a baby or a child.
Do not drive in this situation: ask someone to take you or call an ambulance, which in Europe is 112. Do not eat or drink on the way, because urgent surgery under anaesthetic may be needed. Torsion is commonest in teenagers and young men, but it has to be ruled out at any age.
Where the inflammation comes from
The cause depends a great deal on age and on what happened beforehand.
- In men under thirty-five, sexually transmitted infections come first, chlamydia and gonorrhoea above all. Often this is their only sign: they reach the scrotum without having announced themselves at all.
- In older men the usual culprits are bowel bacteria that have travelled up the urinary tract. They are let through by an enlarged prostate, a narrowed urethra, a catheter or recent surgery on the prostate or bladder.
- After unprotected anal sex, bowel organisms become a likely cause regardless of age.
- Mumps in someone who has not been vaccinated swells the testicle and epididymis a few days after the salivary glands puff up.
- Less often the cause is tuberculosis: the inflammation then drags on for weeks, barely hurts and may break through as a sinus onto the scrotal skin. This picture is easily mistaken for a tumour.
- Amiodarone, a drug used for heart rhythm disturbances, is a case of its own: it causes epididymitis with no infection at all, and everything settles once the doctor adjusts the dose. Some general inflammatory conditions, such as Behçet's disease, behave in a similar way.
- Sometimes the inflammation begins after a blow to the groin or heavy straining, when urine is forced back along the sperm duct.
What happens at the appointment
The doctor looks at and feels the scrotum, the abdomen and the glands in the groin, and asks about passing urine, recent operations and sexual history. That last part is not curiosity: the answer decides which antibiotic is chosen.
The usual tests are:
- a urine test and culture;
- a first-catch urine sample or a urethral swab for chlamydia and gonorrhoea;
- a full sexual health screen if either of those is confirmed;
- an ultrasound scan of the scrotum with blood flow assessment — when examination cannot rule out torsion, when a lump can be felt, or when treatment is not working;
- examination of the prostate in older men and, where episodes keep recurring, investigation of the urinary tract to find what is letting bacteria through.
Treatment and how long it takes
Antibiotics are the mainstay, chosen according to the likely organism: the regimen for a sexually transmitted infection is not the same as the one for bowel bacteria. Sometimes treatment starts with an injection and continues with tablets; sometimes tablets alone are enough. The course usually runs from a week and a half to two weeks, and it must be completed even if things feel fine after three days, because a half-treated infection comes back and responds worse the second time.
If the cause turns out to be a sexually transmitted infection, treating one person alone achieves nothing. All partners from the past several months need testing and treating, and sex is put off until both people have finished the course and for a further week after it ends.
Improvement is usually felt within two or three days. Firm swelling, however, resolves slowly — it can take a month or two, occasionally up to three, and on its own that is not a sign of failure. The sign of failure is no improvement by day three, or getting worse: that calls for another appointment.
What helps at home
Home measures do not replace the antibiotic, but they make the first days noticeably easier.
- Spend the first day or two resting and lifting nothing heavy.
- Wear close-fitting supportive underwear, and when lying down put a rolled towel under the scrotum: raising it reduces the swelling.
- Apply something cold through a cloth for fifteen minutes several times a day. Ice does not go directly on the skin, and heat should not be used either.
- For pain, paracetamol or anti-inflammatory painkillers will do. One important caveat: if you have had seizures, combining anti-inflammatories with certain antibiotics is not advisable, so ask your doctor or pharmacist what suits you.
- Drink enough water and do not hold on when you need to pass urine.
- Until the course is finished, leave out sex, the gym and cycling.
If it does not settle
Sometimes things do not follow the script, and it is worth knowing these possibilities in advance. An abscess can form in the epididymis: pain and fever then persist despite antibiotics and the contents have to be drained. In some men a dull ache remains for months after the infection itself has been cured; that is no longer treated with antibiotics but with pain relief, physiotherapy and pelvic floor work. Inflammation on both sides occasionally worsens semen quality, so if children are planned after a severe episode a semen analysis makes sense.
And the most important point. If a firm, painless lump remains in the testicle once treatment is over, it must not be written off as "what the inflammation left behind". Testicular cancer is the commonest malignant tumour in young men and it is good at hiding behind the picture of epididymitis. Any lump, change in shape or size, or feeling of heaviness that persists after recovery is a reason for another examination and a scan. Found early, it is treated with very good results.
Online consultation
The first step works well remotely: describing how and how fast the pain appeared and working out whether it fits epididymitis or looks like torsion and means going to hospital at once. The doctor can say which tests to arrange before a face-to-face visit, interpret the results, go through the prescribed regimen and its length, and answer the awkward questions about partners and how long to abstain. It is also a convenient way to come back after three days and report whether things have eased, and after a month to discuss the swelling that is left. What cannot be done this way is feeling the scrotum and scanning it. So with sudden severe pain, vomiting or a high temperature, do not message the doctor — call an ambulance.
This material is for information only and does not replace medical advice.
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