The onset of scrotal pain typically occurs over hours and is often referred to the ipsilateral inguinal canal or lower abdominal quadrant. Recent urinary tract instrumentation or urinary tract infection is a risk factor. Early in the course, a tender, indurated, edematous epididymis is palpated separately from the nontender testicle. Late presentations will have generalized scrotal swelling and tenderness, making examination and differentiation more difficult. The urinalysis reveals pyuria or bacteriuria half of the time, and the peripheral white blood cell count is frequently elevated. Patients can present with fever and signs of sepsis. Approximately half the time, the epididymis and adjacent testicle will be inflamed, which is termed epididymo-orchitis.
Management and Disposition
Men under the age of 35 can be treated empirically for sexually transmitted infections (STIs), but also should be treated for enteric organisms if they practice insertive anal intercourse. Older men without other risk factors tend to have enteric organisms and not STIs as the cause of infection and are treated with a fluoroquinolone such as levofloxacin. Most patients can be treated as outpatients, but consider admission and intravenous (IV) antibiotics for febrile patients. Ultrasound is not necessary in classic presentations but may be useful for cases that are not straightforward or for cases where more serious conditions such as testicular torsion are on the differential.
Acute Epididymitis. (A) Swelling of the right hemiscrotum and tenderness of the inferior posterior portion of the testicle. (Photo contributor: Emergency Medicine Department, Naval Medical Center Portsmouth, VA.) (B) Diffuse and erythema swelling of the entire scrotum. (Photo contributor: Cyril Thomas, PAC.)
Elevation of the affected hemiscrotum while standing may provide relief of symptoms (Prehn sign).
Evaluate older men for urinary retention, as this is a frequent cause of epididymitis.
Testicular tumors are most frequently misdiagnosed as epididymitis.
The absence of pyuria or bacteriuria does not exclude the diagnosis.
Referred pain to the lower quadrants can mimic appendicitis or diverticulitis.