Urology · KIMS Secunderabad
Epididymitis and Orchitis — Scrotal Pain, Swelling, and Infection
Epididymitis is inflammation of the epididymis — the coiled tube that runs along the back of each testicle and transports sperm from the testis to the vas deferens. Orchitis is inflammation of the testis itself. The two frequently occur together — epididymo-orchitis — as the infection spreads from the epididymis to the adjacent testis. Together, they are the most common cause of acute scrotal pain in men above 35, and among the most common causes in younger men after testicular torsion.
The clinical importance of correctly diagnosing epididymitis lies in two directions: excluding testicular torsion (a surgical emergency that can cause testicular loss within hours if not operated on, which can be difficult to distinguish from epididymitis clinically) and treating the infection adequately to prevent complications — chronic epididymitis, testicular abscess, infertility from bilateral epididymal scarring, and reactive hydrocele.
Causes by age group
Below 35 years — Sexually transmitted infections
Most common cause: Sexually transmitted infections. Organisms: Chlamydia trachomatis (most common) · Neisseria gonorrhoeae. Clinical clues: often associated with urethral discharge or recent new sexual partner. Urethral swab recommended.
Above 35 years — Enteric organisms
Most common cause: Enteric organisms. Organisms: E. coli · Klebsiella · Pseudomonas. Clinical clues: associated with underlying urological abnormality (BPH, urinary tract instrumentation, urethral stricture). Urine culture positive.
Any age — Specific causes
Mumps orchitis (historically important — viral, no bacterial treatment). Tuberculosis epididymo-orchitis (important in India — TB is a significant cause of unilateral epididymal swelling in Indian patients). Post-vasectomy epididymitis (chemical inflammation from backed-up sperm).
Symptoms
Scrotal pain — typically develops over 1 to 2 days, unlike the sudden onset of testicular torsion. Usually unilateral, starts at the epididymis (posterior and superior to the testicle), and may spread to involve the entire scrotal contents.
Scrotal swelling and erythema — the affected hemiscrotum becomes red, swollen, and warm.
Epididymal tenderness — palpation of the epididymis behind the testicle is exquisitely tender. The testicle itself is initially non-tender in isolated epididymitis.
Fever — present in moderate to severe epididymo-orchitis. Low-grade or absent in mild epididymitis.
Urinary symptoms — dysuria, frequency, and urethral discharge suggest STI-related epididymitis in younger men; voiding symptoms suggest BPH-related epididymitis in older men.
Prehn's sign — elevation of the scrotum relieves pain in epididymitis (from reduced tension on the vas) but worsens pain in testicular torsion. Clinically useful but not reliable enough to distinguish the two without Doppler ultrasound.
Any acute scrotal pain — particularly sudden in onset — must be assessed urgently to exclude testicular torsion. Testicular torsion is a surgical emergency: the window for testicular salvage is 4 to 6 hours from onset. If there is any doubt between torsion and epididymitis, scrotal Doppler ultrasound must be performed immediately. At KIMS, scrotal Doppler is available 24/7. Call 040-4488-5000.
Diagnosis at KIMS
Scrotal Doppler ultrasound — the essential investigation
In epididymitis: increased blood flow to the epididymis and testicle (hyperaemia) on Doppler. In testicular torsion: absent or reduced blood flow to the affected testicle. Ultrasound also identifies abscess, reactive hydrocele, and rules out testicular tumour as an alternative cause of symptoms.
Midstream urine culture and sensitivity
Identifies the causative organism in older men with enteric epididymitis.
Urethral swab and NAAT for Chlamydia and gonorrhoea
Performed in men below 35 or with a sexual history suggesting STI.
Full blood count and CRP
Confirm inflammatory response in moderate to severe cases.
TB workup
Mantoux, CBNAAT sputum, early morning urine for AFB — if TB epididymitis is suspected (chronic presentation, bilateral involvement, contact history, painless firm epididymal mass, or poor response to standard antibiotics).
Treatment
STI-related epididymitis (below 35 years)
Ceftriaxone 500mg IM single dose (for gonorrhoea) plus doxycycline 100mg twice daily for 14 days (for Chlamydia). Partner notification and treatment. Condom use.
Enteric epididymitis (above 35 years)
Ciprofloxacin 500mg twice daily for 14 days, guided by urine culture sensitivity. Treat any underlying urological cause (BPH, stricture) once the acute episode resolves.
Supportive measures
Scrotal elevation (support underwear), analgesics (NSAIDs — ibuprofen or diclofenac for anti-inflammatory effect), rest. Fever management with paracetamol.
Hospital admission — when required
Severe systemic illness (fever above 38.5°C, vomiting, unable to tolerate oral antibiotics), suspected testicular abscess (requires IV antibiotics and possible surgical drainage), immunocompromised patients, diagnostic uncertainty requiring urgent Doppler.
TB epididymitis
Anti-tuberculosis therapy — 6-month RNTCP/WHO protocol (HRZE for 2 months, HR for 4 months). Surgery (epididymectomy) only if medical treatment fails or to confirm diagnosis in diagnostic doubt. Coordinate with chest physician at KIMS.
Book an Urgent Urology Assessment for Scrotal Pain at KIMS
Frequently Asked Questions — Epididymitis and Orchitis
The key distinguishing features: Testicular torsion causes sudden, severe pain — typically waking the patient from sleep or occurring during physical activity — reaching maximum intensity within minutes. There is no fever initially, no urinary symptoms, and no history of gradual onset. The testicle may be riding high (elevated by the twisted cord) and the epididymis may be in an abnormal anterior position. Epididymitis causes pain that builds over 1 to 2 days, usually with fever, urinary symptoms, and tenderness localised to the epididymis behind the testicle initially. However, the clinical distinction is unreliable — scrotal Doppler ultrasound is the definitive test and must be performed immediately if there is any doubt. At KIMS, urgent Doppler is available 24/7.
Yes — bilateral epididymitis causing significant inflammation and scarring can block the epididymal tubes bilaterally, causing obstructive azoospermia (absence of sperm in the ejaculate from obstruction rather than failure of sperm production). This is a recognised cause of male infertility in India, where genital TB-related epididymo-orchitis is an important cause of bilateral obstruction. Prompt and complete treatment of epididymitis — particularly TB epididymitis — reduces the risk of permanent obstruction. Men with bilateral epididymitis and subsequent infertility are assessed at KIMS with semen analysis; surgical sperm retrieval (PESA or TESE) and ICSI are options if bilateral obstruction has occurred.
Yes — recurrent epididymitis can occur if the underlying cause is not treated. In older men, inadequately treated BPH or urethral stricture causing stasis of infected urine allows bacteria to ascend to the epididymis repeatedly. Complete urological assessment — uroflowmetry, post-void residual, and treatment of underlying obstruction — is essential after the first episode of bacterial epididymitis in a man above 40. In younger men, STI re-exposure without condom use causes recurrence. TB epididymitis recurs if the full 6-month anti-TB course is not completed.
Mumps orchitis is inflammation of the testicle caused by the mumps virus — occurring in approximately 20 to 30% of post-pubertal males who develop mumps (it does not occur in pre-pubertal children). It presents with unilateral (or bilateral in 15 to 30% of cases) testicular swelling and pain 4 to 8 days after the onset of parotid gland swelling. There is no specific antiviral treatment — management is supportive (analgesics, scrotal support). Bilateral mumps orchitis causes testicular atrophy and infertility in a proportion of affected men. The MMR vaccine prevents mumps and its orchitis complication.
Yes — genitourinary tuberculosis is an important cause of epididymitis in India, where TB prevalence remains high. TB epididymitis typically presents as a chronic, painless or mildly painful swelling of the epididymis — sometimes with a 'beads on a string' feel of the vas deferens on palpation (from TB granuloma involvement). It can form cold abscesses and scrotal sinuses. Unlike bacterial epididymitis, it does not respond to standard antibiotics. Diagnosis: early morning urine for AFB culture (the most sensitive test), CBNAAT, or epididymal biopsy. Treatment: 6-month RNTCP protocol. At KIMS, TB epididymitis is evaluated with the nephrology team (for concurrent renal TB) and treated with the chest medicine team.
KIMS Secunderabad — Dr. Neil Narendra Trivedi (MCh Urology, Member SIU), 24/7 scrotal Doppler ultrasound for torsion exclusion, urine culture, STI NAAT testing, TB workup for chronic presentations, complete antibiotic treatment protocols, male infertility assessment for post-epididymitis semen analysis. Call 040-4488-5000.