What are Epididymitis and Orchitis?

Pain in the scrotum or testicle (“teste”) might be from epididymitis, orchitis or both.

  • Epididymitis is swelling or pain in the back of the testicle in the coiled tube (epididymis) that stores and carries sperm.
  • Orchitis is swelling or pain in one or both testicles, usually from an infection or virus.

This article will help you manage these health issues with your urologist.

What Happens under Normal Conditions?

Male Reproductive Organs
Male Reproductive Organs

The male reproductive system makes, stores, and transports sperm. Sperm is created with special male hormones in the body. These are made in the two testes in the scrotum,(which is the pouch-like sac at the base of the penis). Sperm start growing in the testes and gain movement and maturity while travelling through the epididymis. The epididymis is a coiled tube behind each teste.

Each epididymis is linked to the ejaculatory duct by a tube called the vas deferens. This tube runs from the lower part of the scrotum into the inguinal canal. It then moves through the pelvis, behind the bladder. This is where the vas deferens joins with the seminal vesicle and forms the ejaculatory duct. When you ejaculate, fluid from the seminal vesicles and prostate mix with sperm to form semen. The semen travels through the urethra and comes out the end of the penis.

What are Epididymitis, Orchitis and Epididymo-orchitis?

Epididymitis is when the epididymis swells. This disease can be acute (sudden) or chronic (long-term) and is typically from a bacterial infection. Acute epididymitis is felt quickly with redness and pain, and it goes away with treatment. Chronic epididymitis typically is a duller pain, develops slowly and is a longer-term problem. Symptoms of chronic epididymitis can get better, but may not go away fully with treatment and may come and go. Most cases of epididymitis are seen in adults.

Orchitis is swelling of the teste alone is uncommon. It almost always comes on quickly and goes away with treatment. Chronic orchitis isn’t well-defined. It’s thought to be part of a health issue called orchalgia (chronic testicular pain).

Epididymo-orchitis is the sudden swelling of both the epididymis and the teste.



Symptoms

Acute Epididymitis and Acute Epididymo-orchitis

Infections in the scrotum may be caused by an infection somewhere else in the body. The symptoms can be felt in the infected epididymis and/or teste, and in other parts of the groin area.

In some cases, the main symptom you'll notice is pain in the scrotum. The pain starts at the back of one teste. But it can soon spread to the whole teste, scrotum, and sometimes the groin. The skin might also be swollen, tender, red, firm, and warm. The whole scrotum can also swell up with fluid ("hydrocele").

Some sources of infection and their symptoms are:

Infection of the urethra ("urethritis")

  • Pain and/or burning with urination or blood with urine
  • Pain in the penis and groin area

Infection of the bladder ("cystitis")

  • Pain in the lower part of the abdomen
  • The need to urinate often, suddenly, with a burning feeling

Infection of the prostate ("prostatitis")

  • Pain between the scrotum and the anus
  • The need to urinate often, suddenly, with a burning feeling

Infection of the kidney ("pyelonephritis")

  • Fever
  • Pain in your side

Chronic Epididymitis

Chronic epididymitis pain is felt only inside the scrotum. It's less severe than an acute condition. It can be intermittent, may require antibiotics or anti-inflammatory medication or may go away by itself. The skin isn't swollen, tender, red, firm, or warm.

Acute Orchitis

The symptoms for orchitis are uncommon and can be from a viral or bacterial infection. Pain can start in one teste, and can spread to the whole scrotum. The skin might also be swollen, tender, red, firm, and warm. You may have fever. The whole scrotum can swell and feel painful.

Symptoms for orchitis caused by the mumps virus ("mumps orchitis") include:

  • Mild to severe pain
  • Tenderness
  • Swelling

If the mumps virus are the cause, pain in the teste can appear up to 7 days after glands in the face swell.



Causes

Acute Epididymitis

An "acute" case is most often caused by an infection from bacteria. The e-coli bacteria are a common cause for infection.

  • In children who haven't reached puberty, the infection may start in the bladder or kidney. It then spreads to the teste. Some boys get more urinary tract infections, and may get this more often.
  • In men, a STD (sexually transmitted disease) is one of the causes. Mostly from chlamydia, mycoplasma or rarely gonorrhea. These infections start in the urethra. They can then move into the teste. Sometimes there is a discharge of fluid from the urethra.

Sometimes it is caused by something else:

Epididymitis is sometimes caused by other things:

  • Chemical or inflammatory non-bacterial epididymitis may happen from urine flowing backwards to the epididymis. This is most often from heavy lifting. The urine causes swelling but no infection.
  • The drug "Amidarone" can be a cause but this is rare
  • An infection from the bloodstream (as with tuberculosis)
  • Other unknown causes

In any of these cases, the first sign of a problem is often pain in the back of the teste.

Chronic Epididymitis

A "chronic" case may result after acute epididymitis. It doesn't seem to go away. It can also happen without acute symptoms or known infection. In this case, the cause is unknown.

Orchitis

Orchitis alone is mostly from a mumps virus (or other virus) infection. "Mumps orchitis" appears in about 1/3 of males who get mumps after puberty. It only occurs in boys that have mumps AFTER puberty. In some cases of mumps, interferon can be given to prevent orchitis. This infection doesn't spread to the epididymis.

Acute Epididymo-orchitis

Acute epididymo-orchitis is most often from a bacterial infection. It can also be caused by a tuberculous infection of the epididymis, but this is rare. Rarely, it can start in the teste and spread to the epididymis.



Diagnosis

Your health care provider will ask about your past health and examine you. He/she may test a urine sample and look for bacteria under a microscope. He/she may also try to grow a culture of the urine sample . In acute epididymitis the urine is often infected. In chronic epididymitis the urine typically is not infected.

If your provider thinks you have urethritis, they may test a swab of fluid from your urethra. If your pain came on quickly and severely, he/she may use ultrasound to look more closely at your testicle. Ultrasound is a non-invasive test. It uses sound waves bouncing off structures in your body to make a picture. Ultrasound can measure the blood flow in the epididymis, examine the inside of the testis and see other changes in that area of the body.

Other tests may be used, but not often.

The right diagnosis makes sure you get the right treatment.



Treatment

Acute Epididymitis and Acute Epididymo-orchitis

Treatment often starts with a 1-2 week course of antibiotics. Most cases can be treated out of the hospital with pills. The best medicine for you will depend on the type of bacteria found. The most common antibiotics used are:

  • Doxycycline
  • Ciprofloxacin
  • Levofloxacin
  • Trimethoprim-sulfamethoxazole

For bad cases of infection, you may need to stay in the hospital for treatment. These are cases with pain that's hard to control with vomiting, high fever and if you are not getting better with antibiotics given by mouth. Occasionally, for bad cases, narcotics are needed for a few days.

Tuberculosis epididymitis is more serious but is very rare. It is treated with anti-tuberculous drugs. If damage is bad, surgery may be needed to take out the teste and the epididymis ("orchiectomy").

Epididymitis caused by amidarone is treated by limiting or stopping the drug. Your health care provider will tell you what to do.

For other types of non-infectious epididymitis, there's no set treatment.

Epididymitis care involves rest for 1 – 2 days with the scrotum raised if possible. The aim is to get the inflamed area above the level of the heart. This helps blood flow, which lowers swelling and pain, and helps with healing. Putting ice on the scrotum now and then can also help. In cases due to infection, it helps to drink fluids.

Anti-inflammatory pills like ibuprofen or naproxen help ease pain. They also ease the swelling that causes the pain. If the pain is severe, a short-term narcotic pain medicine may help but is only used for a short period of time at best in most situations.

Chronic Epididymitis

Chronic epididymitis is mainly treated with drugs and comfort to ease pain. Pain medicine and applying heat are the standard treatments.

If symptoms don't go away, your health care provider may suggest other pain medicine. Or, recommend a pain management specialist. If all else fails, the epididymis can be surgically removed ("epididymectomy"). The teste can be left in place.

Acute Orchitis

Antibiotics are often the best treatment for bacterial infections. Pain medicine may help reduce symptoms.

There's no set care for acute mumps orchitis and this will usually resolve in time.



After Treatment

Acute Epididymitis and Acute Epididymo-orchitis

For infectious cases, it takes two to three days to start feeling better. If you don't, and if the redness doesn't begin to fade, call your provider. Discomfort can last for weeks to months after the full course of antibiotics is taken in some cases. It can take months for the swelling to ease. Rest with the scrotum raised for a day or two helps speed healing.

Cases of tuberculous epididymitis (without surgery) may need months to heal with medicine. The teste may shrink after treatment.

Amidarone epididymitis simply gets better after cutting the dose or stopping the drug.

Chemical epididymitis heals fully with treatment.

Please follow-up with your health care provider to make sure the problem doesn't return.

Chronic Epididymitis

Symptoms for chronic epididymitis go away eventually or may come and go. Anti- inflammatory medicine may be needed on and off for a months or years. Symptoms are sometimes better and sometimes worse.

If surgery is done, symptoms ease in most men after a few weeks of healing. If surgery hasn't helped, your health care provider will try drugs again. In certain cases, he/she may suggest microsurgery to block nerves on the spermatic cord.

Acute Orchitis

Pain often goes away after the acute phase. The teste often shrinks.



Frequently Asked Questions

What if the swelling and pain don't get better after three days of antibiotics?

Most acute cases are treated well by antibiotics. Sometimes, a different antibiotic needs to be used or you may require hospitalization with stronger antibiotics given into your veins. If antibiotics don't stop the symptoms, your health care provider may suspect tuberculous epididymitis. If a pocket of pus ("abscess") has formed, more must be done. Surgery to drain the abscess or remove part or all of the epididymis might be needed. This is rare. Other problems that might need surgery: teste death with destroyed blood vessels ("testicular infarction"); an infection that drains through the skin ("cutaneous fistula").

Can I pass the infection to my sex partner?

  • Yes, if the infection is from an STD. (This is most often the cause in men under 40 who have sex.) In this case, the infection can be passed back and forth through sex. Your sex partner needs to be treated as well.
  • No, if the infection is from bacteria in the urinary tract. There is no risk of infecting your partner in this case.

Will my ability to father children be reduced?

If your teste has shrunk due to mumps orchitis or tuberculous epididymitis, the teste will make less sperm. In rare cases, the epididymis may be blocked after an infection. This would also reduce sperm from that teste. If only one teste is affected, then most men are able to father a child normally.

Will hormone production by the teste be affected?

In most cases, hormones and sperm production are not affected. In rare cases, the affected teste may not be able to make testosterone or sperm. Ask your urologist to find out how you're doing.

Do epididymis or testicular infections lead to cancer?

These infections are not linked to cancer. However, in cases that are not getting better, a physical examination by a urologist and/or an ultrasound may identify something else as the cause of the pain. Most cancer of the testes are painless, but a small percentage will start with pain in this area of the body.