Condition: Chronic Epididymitis
Brief Overview: According to UpToDate, “Chronic epididymitis may be infectious or noninfectious in origin.
- Chronic infectious epididymitis– Although rare, chronic infectious epididymitis presents with localized tenderness and swelling in the epididymis, distinct from any tenderness or abnormality in the testis (usually without lower urinary tract symptoms) and may occur in healthy adolescents and men. Several factors, including sexual activity, heavy physical exertion, and bicycle or motorcycle riding may predispose to it. Patients who present with chronic or recurrent epididymitis should be evaluated for a structural abnormality of the urinary tract by CT scan with contrast and possibly prostate ultrasonography [21-23]. Physical examination shows subtle epididymal induration and tenderness with or without swelling. In all suspected cases, a urinalysis, urine culture, and urine nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis should be performed. Management is identical to that of acute infectious epididymitis but may rarely extend to surgical management. (See "Acute epididymitis in adolescents and adults", section on 'Management'.)
- Chronic noninfectious epididymitis– Chronic noninfectious epididymitis can be precipitated by trauma, autoimmune disease, amiodarone use, or vasculitis, but no etiology is identified in most cases [24,25]. Idiopathic noninfectious epididymitis is thought to be the result of reflux of urine through the ejaculatory ducts and vas deferens into the epididymis, producing a "chemical" inflammation with resultant swelling and ductal obstruction. It can occur, however, even in men who have had a previous vasectomy. Typical inciting factors include prolonged periods of sitting (long plane or car travel, sedentary desk jobs) or vigorous exercise (heavy lifting). Unlike acute infectious epididymitis, patients tend to have less tenderness and swelling on physical examination. The diagnosis is made by performing a careful history and physical examination. Often patients will present with a history of not improving on prior antibiotic therapy. Management includes scrotal elevation, nonsteroidal anti-inflammatory drugs (NSAIDs), and avoidance of activities that precipitate symptoms. Amiodarone should be discontinued [25]. Men in sedentary jobs or who sit in planes or cars for prolonged periods of time should be advised to get up and walk around for a minute or two every hour if possible.”
Etiology:
- Can be idiopathic (no known etiology)
- Infectious
- prior Chlamydia/Gonorrhea
- chronic bacterial prostatitis
- rarely TB (granulomatous)
- Noninfectious
- Amiodarone use
- Vasculitis
- Trauma
- Autoimmune disease
Risk Factors:
- Vigorous heavy lifting/exercise
- Long periods of sitting
- Chlamydia/gonorrhea
- Chronic prostatitis
- Multiple sexual partners/unprotected intercourse
Commonly Associated Conditions:
- Chronic pelvic pain syndrome (CPPS)
- Inguinal hernia
- Chronic prostatitis
Common Medications:
- NSAIDs
- Antibiotics if infectious
Common Labs, Imaging, and Tests:
- Urine testing
- STI testing
- Ultrasound, CT
Common Symptoms:
- Scrotal pain/tenderness – typically described as a dull ache
- Swelling
Common Treatments:
- Heat/ice therapy
- Scrotal elevation
- Avoid activities that induce symptoms
- Surgical intervention may be indicated
Physical Findings:
- Localized tenderness of epididymis; possible induration or thickening
Potential Complications and Contraindications:
- Chronic scrotal pain affecting function/quality of life
- Male infertility
- Anxiety/depression related to persistent pain
- Scrotal abscess
- Contraindication: amiodarone should be discontinued, if applicable (Patients should not stop medication on their own. Patients should always follow the advice and guidance of their healthcare provider. If patient is prescribed amiodarone, advise the patient to discuss this further with their healthcare provider.)
General Health and Lifestyle Guidance:
- Supportive underwear; limit prolonged sitting/cycling
- Ice/heat as preferred; ask your healthcare provider if you should avoid heavy straining/constipation
- Maintain adequate hydration; avoid bladder irritants if voiding symptoms present
- Safe sexual practices; encourage partners to get tested/treatment when STI suspected
- Set realistic expectations: improvement may be gradual; multimodal care may work best
Suggested Questions to Ask Patients:
- Duration and pattern of pain (constant vs activity-related)? Any swelling or lumps?
- Recent STI risks, new partners, or prior UTIs/prostatitis?
- Exposures: prolonged sitting, cycling, heavy lifting, recent procedures, vasectomy?
- Urinary symptoms (frequency, perineal pain), ejaculatory pain?
- Prior treatments (antibiotics, NSAIDs, PT) and response?
- Impact on work, activity, sexual function, mood?
- TB risks (travel, exposure), systemic symptoms (night sweats, weight loss)?
Suggested Talking Points:
- Antibiotics help when tests suggest infection; otherwise, your healthcare provider will likely prioritize non-antibiotic strategies.
- Supportive underwear, activity modifications, and consistent PT can meaningfully reduce symptoms.
- If pain is localized and persistent, nerve blocks or surgery may be options after evaluation.
- Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.
Sources:
- https://www.uptodate.com/contents/nonacute-scrotal-conditions-in-adults?search=chronic%20epididymitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3389120289
- https://www.urologyhealth.org/urology-a-z/e/epididymitis-and-orchitis
- https://my.clevelandclinic.org/health/diseases/17697-epididymitis