Patient's question:
My right testicle is hard, without elasticity, and I feel pain. Patient's gender: Male Patient's age: 23 Current general condition: Always feel pain, and the right epididymis also hurtsDoctor's answer:
Here is the English translation of the provided text, with Chinese content translated and original line breaks preserved:---
Dear Member of the Medical Garden,
The epididymis is a part of the male reproductive system and is divided into three parts: the head, body, and tail. The head is connected to the testis, and the tail extends into the vas deferens. The efferent ductules of the testis form the head of the epididymis through coiling, and ultimately merge into a single epididymal duct. The epididymis has the function of storing and transporting sperm. After sperm production, they first enter the efferent ductules and then the curved epididymal duct, where they remain at the tail to continue maturing. The area you mentioned, posterior and inferior to the testis, is precisely where the tail of the epididymis is located. When a large amount of sperm is stored there, it may be possible to feel a hard lump; after ejaculation, when sperm is expelled, this lump will soften.
### (1) Etiology
Epididymitis has three common causes:
① Secondary to prostatitis or urinary tract infection.
② Prostatectomy, especially transurethral surgery, as postoperative urine may contain bacteria for 8–12 weeks. During urination, urine may reflux into the vas deferens, causing retrograde infection and leading to epididymitis. Infection can also spread to the epididymis through surrounding lymphatic vessels.
③ Chemical epididymitis caused by sterile urine refluxing into the vas deferens. Recent studies have found that urine can reflux into the seminal vesicles as well.
### (2) Pathophysiology and Pathology
Early epididymitis is a cellulitis that starts in the vas deferens and spreads to the tail of the epididymis. In the acute phase, the epididymis swells and becomes hard, with infection spreading from the tail to the head. On pathological slides, small abscesses can be observed, and the tunica vaginalis may secrete serous fluid (inflammatory hydrocele). This fluid may contain pus, the spermatic cord may thicken, and the testis may become secondarily congested and swollen, though inflammation is usually absent. Under light microscopy, tissue edema, neutrophils, plasma cells, and lymphocytes infiltrate, followed by abscess formation. Epithelial necrosis may occur, and inflammation can be completely absorbed. However, fibrosis around the epididymal tubules often leads to lumen obstruction, and bilateral epididymitis can cause infertility.
### (3) Differential Diagnosis
1. Tuberculous Epididymitis
- Pain is rare, and the epididymis and testis are clearly demarcated on palpation. The vas deferens appears beaded, the prostate surface is uneven, both seminal vesicles are thickened, and "sterile" urine is observed on smear, while Mycobacterium tuberculosis can be cultured.
2. Testicular Tumor
- Presents as a painless mass. Acute hemorrhage within the tumor may cause sudden increased pressure on the tunica albuginea, leading to testicular and epididymal pain. The testicular mass can be distinguished from the normal epididymis, and prostate examination and urine analysis are normal. If doubts remain, human chorionic gonadotropin (hCG) testing may be positive in about 15% of cases. If diagnosis is uncertain, intraoperative rapid pathology is recommended to decide whether orstration is necessary.
3. Testicular Torsion
- Common in prepubertal children and occasionally in adults. Epididymitis is more common in older age groups. In early testicular torsion, the epididymis is palpable anterior to the testis, and the testis is retracted superiorly. Later, the epididymis and testis form a swollen, painful mass. The Prehn sign helps differentiate: if lifting the scrotum to the pubic symphysis alleviates pain, it is likely epididymitis; if pain worsens, it is likely torsion. If torsion cannot be ruled out, surgical exploration is warranted.
4. Testicular or Epididymal Appendage Torsion
- A rare condition in prepubertal boys. These pedunculated structures can wrap around, causing localized pain and swelling. Early on, a hard nodule may be palpable at the superior pole of the testis, while the epididymis appears normal. In advanced stages, the entire testis swells, making it difficult to distinguish between epididymitis, torsion, or appendage torsion. Since testicular torsion requires immediate treatment, active surgical exploration is recommended in such cases.
5. Testicular Injury
- Can cause acute epididymitis, but a history of trauma and absence of purulent urine help differentiate.
6. Mumps-Induced Orchitis
- Typically occurs with mumps and often lacks urinary symptoms. Urinalysis shows no pus cells or bacteria.
### (4) Complications
Abscess formation is rare but may occur after urethral instrumentation or prostate massage. The abscess may drain spontaneously into the scrotum or require surgical drainage. Epididymal abscess can extend and damage the testis (epididymo-orchitis), though this is uncommon.
### (5) Prevention
Prostatitis and urinary tract infections should be treated thoroughly. If recurrent acute epididymitis persists, bilateral vas deferens ligation may be performed to prevent recurrence.
### (6) Treatment
1. Specific Treatment
- If the patient seeks medical attention within 24 hours of onset, infiltration anesthesia with 1% procaine (20 mL) or lidocaine at the spermatic cord superior to the testis may completely relieve symptoms. Body temperature typically drops rapidly, pain disappears, and inflammatory masses resolve within days. If a single injection is insufficient, a second may be administered the next day. Antibiotics aid treatment and secondary cystitis resolves quickly. Antibiotic selection should be based on bacterial culture and sensitivity tests. Common drugs include cotrimoxazole, ciprofloxacin, ofloxacin, and third-generation cephalosporins, all of which are effective.
2. General Treatment
- During the acute phase (3–4 days), bed rest is recommended. A scrotal support may alleviate symptoms, and a homemade scrotal support with cotton padding is more comfortable. Painful cases may require analgesics, and local heat therapy can relieve symptoms and promote inflammation resolution. However, early heat application may worsen pain and risk infection spread, so ice packs are preferred initially. Sexual activity and physical labor should be avoided.
### (7) Prognosis
Acute epididymitis responds well to treatment, with symptoms gradually resolving within 1–2 weeks. However, it takes 4 weeks or longer for the epididymis to return to normal size and texture. Complications are rare, but bilateral epididymitis may cause infertility.
Testicular pain can be broadly categorized into two types: acute persistent pain and chronic intermittent pain. Acute pain is more common in orchitis and injury. Orchitis, apart from hematogenous infection, is more frequently caused by bacterial retrograde infection via the urethra to the epididymis and testis, leading to swelling and pain. Testicular injury is associated with trauma, local swelling, and ecchymosis. Intense exercise, sexual activity, or violence may cause strong contraction of the cremaster muscle, leading to torsion in excessively long testes and severe pain. Due to blood supply obstruction after torsion, the testis becomes swollen and the scrotal skin edematous. Acute pain is relatively easier to diagnose.
What if the penis and testis are small?
Chronic pain may persist for a long time, mild, diffuse, and radiating, making it difficult to pinpoint the exact location of inflammation. Testicular pain does not always correlate with the severity of inflammation. Some individuals with high sensitivity may experience severe pain from mild inflammation, while others may perceive it as mild. Pain may occur after sexual activity, possibly due to heightened congestion in genital and gonadal tissues. Pain may also radiate from varicocele or other sources, such as ureteral stones causing radiating testicular pain. In such cases, careful differentiation of the true cause is essential for effective symptomatic treatment.
### (8) Treatment
Treatment should be based on identifying the underlying cause and providing symptomatic relief. If the cause is unclear, sedation and analgesics may be used. Prilocaine block of the spermatic cord may be employed to interrupt the vicious cycle between neural pain and the central pain pathway. Some individuals may experience testicular pain with minimal or no discomfort, purely due to psychological factors. Others may link pain to masturbation, burdened by guilt. However, excessive anxiety and overemphasis on sexual performance may lead to psychological impotence and other sexual dysfunctions.
Be cautious of orchitis
There are many potential causes of testicular pain, making self-diagnosis difficult. Avoid self-medication and seek early consultation with a specialist to prevent delayed treatment.
#### Medications for Orchitis
1. Bacterial Orchitis
- Procaine penicillin (8 million units, BID IM) or gentamicin (80,000 units, BID IM) for 5–7 days. After inflammation subsides, oral antibiotics such as cefixime, cotrimoxazole, or ofloxacin may be used.
2. Traditional Chinese Medicine (TCM)
- Principles: Clear heat, resolve toxicity, and calm liver fire. Medications include gentiana, bupleurum, phellodendron, baical root, plantain, and alisma. For viral orchitis, honeysuckle, Forsythia, radix isatidis, scutellaria, dandelion, and indigo naturalis may be used. Alternatively, Radix isatidis injection (2 mL, BID IM) may be administered.
3. Topical Medications
- Application of red bean powder mixed with duck egg white to the scrotum, or Huangyi (mixed with vinegar) applied daily 1–2 times, can reduce pain and aid testicular swelling.
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