It's not too uncommon to see a man present to the clinic with pain in their scrotum, and it always causes a bit of embarrassment, and of course, a bit of fear. The most common reason is #epididymitis, when the spermatic cord in the back of the testicles becomes inflamed. This is pretty painful, as I am told.
Often this is accompanied by inflammation in one of the testicles as well, which together is called epididymo-orchitis (McConaghy & Panchal, 2016; Rupp & Leslie, 2023). When this inflammation and swelling is present for less than six weeks, we consider this acute, but it can become more chronic when the pain lasts three months or more. Among adult men, nearly half of cases occur between the ages of 20 and 30 years, and just over half have both epididymitis with #orchitis. Epididymitis can occur in those as young as 13 years, but not often beyond 35 years of age.
Certainly when any aspect of the genitals is inflamed, we have to consider sexually transmitted disease, but a history of any surgery to this area also poses risk (Rupp & Leslie, 2023). Prolonged sitting, bicycling, and trauma, potentially related to sports activities, can all be risk factors for epididymitis as well. Though rare, chemical epididymitis may occur as a result of exercising or having sexual intercourse with a full bladder, resulting in a retrograde flow of urine.
Men will typically complain of pain on one side of the #scrotum, with more swelling also notable to one side (McConaghy & Panchal, 2016). Generally symptoms get worse over two days, and some will have fever or blood in their urine. They may have to use the restroom frequently and the pain may radiate into the lower abdomen. This more gradual onset helps us differentiate epididymitis from #torsion because the latter is fairly sudden in onset, and much more severe, without fever or bluish discoloration. Interestingly, when the scrotum is lifted, the pain is somewhat alleviated with epididymitis.
When younger boys present with these symptoms, we question if potentially there is some level of anatomic abnormality or maybe some reflux of urine into the ejaculatory ducts (McConaghy & Panchal, 2016). Infection might be part of the cause as well, such as Mycoplasma pneumoniae, enterovirses, and adenoviruses. When especially young, in the first decade of life, Henoch-Schonlein purpura, a common form of vasculitis, should be ruled out.
In adult men though, consider Chlamydia trachomatis and Neisseria gonorrhoeae (McConaghy & Panchal, 2016). When older than 35 years, epididymitis is more often related to retrograde flow of infected urine into the ejaculatory duct generally because of some sort of bladder outlet obstruction, potentially an enlarged prostate. An inguinal #hernia may also present similar to epididymis with swelling and tenderness. The hernia can typically be discerned by the clinician on exam though. We can't overlook causes that are more typical to those who are immunocompromised, such as men with HIV. Cytomegalovirus, Salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium, Mycoplasma, the mumps, and mycobacteria are additional causes. There are a few medications, such as amiodarone, which can irritate this area as well, which isn't necessarily infectious. Sarcoidosis and Behcet syndrome are other potential causes, as well as cancer.
Your clinician will order a urinalysis or dip the urine in the clinic to evaluate for potential infection (McConaghy & Panchal, 2016; Rupp & Leslie, 2023). A urine culture will also be ordered for children, and for adult men who have any indication of infection with the urinalysis. N. gonorrhoeae and C. trachomatis should be ruled out in those who are sexually active. If there is concern of torsion, an ultrasound will be ordered. Typically with epididymitis, the ultrasound will identify swelling and increased blood flow, but if decreased or absent flow is identified, then testicular torsion is more likely. Lab results may show an elevated c-reactive protein level.
How is Epididymitis Treated?
When epididymitis is diagnosed in young children, when symptoms are limited to just the scrotum and there is not fever, antibiotics can be reserved for when the urinalysis or urine culture indicate they are necessary (McConaghy & Panchal, 2016). Older than 14 years of age though, antibiotics are typically recommended with aim towards the most likely pathology, specifically gonorrhea and chlaymydia. If left untreated, chronic pain and even infertility can result. When laboratory results return, they can better direct treatment. Older than 35 years though, again, sexually transmitted disease is not as great of a risk, so less aggressive antibiotics are the preferred approach.
Tylenol and Ibuprofen are recommended for pain relief and to reduce inflammation. Wearing a jock strap can help lift the testicles or scrotum, reducing the strain and therefore, pain. Ice too may be helpful. When pain is more severe, hospitalization may prove necessary. Systemic infection may occur as well, requiring intravenous #antibiotics.
Symptoms should improve within two to three days of treatment, but residual pain may persist for several weeks (McConaghy & Panchal, 2016). Children younger than 14 years who are treated for acute epididymitis should be evaluated for urinary tract obstruction due to prostatic enlargement. When treating for sexually transmitted disease, partners should be notified. Of course, some suspicious of sexual abuse in younger boys should be considered, with the understanding that one in six boys are sexually assaulted.
References
McConaghy, J & Panchal, B. (2016). Epididymitis: an overview. American Family Physicians, 94(9), 723-726. https://www.aafp.org/pubs/afp/issues/2016/1101/p723.html
Rupp, T. J. & Leslie, S. W. (2023, July). Epididymitis. [StatPearls]. https://www.ncbi.nlm.nih.gov/books/NBK430814/