EM@3AM – Epididymitis

Author: Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 29-year-old male, with no previous medical history, presents to the emergency department for three days of progressively worsening dysuria and left testicular pain. The man denies fever, abdominal pain, hematuria, urethral discharge, and testicular trauma. He reports unprotected intercourse with two new sexual partners within the previous 30 days.

Initial VS: BP 119/76, HR 77, T 99.7F Oral, RR 14, SpO2 99% on room air.

Physical examination:
General: Thin, well-developed male; appearing as stated age.
Abdomen: Soft, non-tender, non-distended; no guarding, or rebound.
GU: Tanner stage V, no evidence of inguinal hernia, no scrotal edema, urethral discharge, or visible lesions. TTP of the left epididymis.

What do you suspect as a diagnosis? What’s the next step in your evaluation and treatment?

Answer: Epididymitis1-5

  • Epidemiology: Epididymitis accounts for > 600,000 visits to physicians in the U.S. annually.1
  • Pathogens:
    • Males < age 35: C. trachomatis (most common) and N. Gonorrhoeae are the major pathogens.1
    • Males > age 35: Gram negative coliforms, enterococci, and Pseudomonas species frequently isolated from cultures.2
  • Clinical Presentation: Patients frequently report dysuria. Testicular pain, urethral discharge (rare in the setting of C. trachomatis infection), suprapubic discomfort, and fever may also occur.1
    • Sexually transmitted infections (STIs): median interval from exposure to clinical manifestation: 10 days.3
      • Males may carry chlamydiae for long periods before developing overt epididymitis.3
    • Gram negative coliforms, enterococci, and Pseudomonas species: onset commonly subacute (1-2 days).
      • Infection may occur weeks to months (rare) following urethral catheterization or surgical manipulation.
      • Epididymitis may rarely occur following genital trauma.1
  •  Evaluation and Treatment:
    • Assess the ABCs and obtain vital signs.
    • Perform a thorough H&P: Obtain sexual history and question regarding recent urethral instrumentation.
    • GU examination may be significant for:
      • Epididymal TTP (posterior aspect of the scrotum).
      • TTP and swelling of the involved testis (suspect epididymo-orchitis).
      • Presence of a hydrocele => inflammatory fluid collection between the layers of the tunica vaginalis.
      • Urethral discharge.
    • Laboratory evaluation: Urinalysis, urine culture, STI testing as appropriate (e.g. urine nucleic acid amplification test (NAAT), urine culture, urethral swab).
    •  Treatment:
      • Epididymitis thought secondary to sexual exposure: ceftriaxone + azithromycin or doxycycline.
        • Requires patient counseling regarding treatment of sexual partner.
        • Requires communicable disease reporting if NAAT or culture positive .4
      • Epididymitis thought secondary to coliforms: empiric antibiotic therapy directed against gram negative rods and gram positive cocci (utilize culture to target therapy).
    •  Complications: Untreated bacterial epididymitis may result in: bacteremia, testicular infarction, scrotal abscess, pyocele, a chronic draining scrotal sinus, chronic epididymitis, and infertility.
  • Pearls:
    • In children presenting with epididymitis (absent indications/findings consistent with sexual abuse) => suspect anatomic urinary tract abnormality.1
    • Patients taking amiodarone may present with signs/symptoms of epididymitis:5
      • Amiodarone is known to induce epididymalgia in 3-11% of individuals compliant with prescribed therapy => mechanism is currently unknown; hypothesized that accumulation of a metabolite in epididymal tissue results in focal fibrosis and lymphocytic infiltration (UA and culture are negative).  Analgesia is the treatment of choice.5
    • Failure of resolution of epididymitis signs/symptoms within 72 hours of therapy: re-evaluation required => consider testicular abscess, carcinoma, testicular infarction, or fungal epididymitis.


  1. McGowan C, Krieger J. Prostatitis, Epididymitis, and Orchitis. In Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA. Elsevier Saunders. 2015; 112: 1381-1387.e2.
  2. Doble A, Taylor-Robinson D, Thomas B, et al. Acute epididymitis: a microbiological and ultrasonographic study. Br J Urol. 1989; 63:90-94.
  3. Berger R, Alexander E, Harnisch J, et al. Etiology, manifestations, and therapy of acute epididymitis: a prospective study of 50 cases. J Urol. 1979; 121: 750-754.
  4. Chorba, Berkleman, Safford, and Hull. Mandatory Reporting of Infectious Diseases by Clinicians. Centers for Disease Control and Prevention. 1990. Accessed 12 Aug 2017. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001665.htm
  5. Shen Y, Liu H, Cheng J, Bu P. Amiodarone-induced epididymitis: a pathologically confirmed case report and a review of the literature. Cardiology. 2014; 128(4):349-351.


For Additional Reading:

Foley Catheter Patients: Common ED Presentations/Management/Pearls & Pitfalls


Foley Catheter Patients: Common ED Presentations / Management / Pearls & Pitfalls

Leave a Reply

Your email address will not be published. Required fields are marked *