Patient's question:

Currently, the general situation: Testicular swelling, with a slight sense of fullness and pressure. Medical history: About five or six years ago, this condition occurred occasionally, and now the symptoms have been present for a long duration. Is it epididymitis?

Doctor's answer:

Hello! First of all, I wish you a speedy recovery! I would like to discuss the issue of "epididymitis" with you. Epididymitis is the most common infectious disease in the scrotum, often occurring in young and middle-aged adults. Bacteria usually spread from infected urine, the prostate, the posterior urethra, or the seminal vesicles through the vas deferens to the epididymis. Patients who have undergone prostate surgery or have indwelling catheters are also prone to epididymitis. Urine reflux into the vas deferens during urination can also lead to epididymitis. If a child experiences recurrent epididymitis, it should be considered that the ureteral opening may be into the seminal vesicle. Common bacteria that cause epididymitis include Escherichia coli and Staphylococcus, as well as Mycobacterium tuberculosis, Neisseria gonorrhoeae, and Chlamydia. Since the epididymis is the site where sperm mature and are stored, it plays a crucial role in fertility. Bilateral epididymal disease can cause infertility. Epididymitis can be divided into acute epididymitis and chronic epididymitis.
1) Etiology
Acute epididymitis is often caused by the spread of infection from the urinary system, prostatitis, or seminal vesiculitis along the vas deferens to the epididymis, with hematogenous infection being less common. Cystoscopy, frequent catheterization, and indwelling catheters after prostatectomy are all risk factors for epididymitis. If acute epididymitis is not treated thoroughly, it can progress to chronic epididymitis.
2) Symptoms
1. Acute Epididymitis
Clinical manifestations of acute epididymitis include sudden onset, scrotal swelling and pain, high sensitivity to touch, and radiation to the groin and lower abdomen. The size can double within hours, and white blood cell count can rise to 20,000–30,000/cubic millimeter. Pain worsens when standing and is often accompanied by high fever. The affected scrotum feels swollen, heavy, and aching, with pulling pain in the lower abdomen and groin, which intensifies when standing or walking. The affected epididymis is enlarged and tender. When inflammation is extensive, both the epididymis and testis may swell, turn red, and form abscesses. The boundaries become indistinct, a condition known as epididymitis orchitis. The spermatic cord on the affected side may also thicken and become tender. Generally, acute symptoms gradually subside within a week.
2. Chronic Epididymitis
Chronic epididymitis is clinically more common, with some patients developing it from unresolved acute episodes, while others have no clear acute phase, often secondary to chronic prostatitis or injury. Patients often experience a dull ache or heavy sensation in the affected scrotum, with pain radiating to the lower abdomen and the same side of the groin. Secondary hydrocele may also occur. Examination may reveal varying degrees of enlargement and hardness of the epididymis, mild tenderness, and thickening of the ipsilateral vas deferens.
3) Differential Diagnosis
1. The vas deferens in epididymal tuberculosis appears as a string of beads.
2. Epididymal tuberculosis often causes adhesions to the scrotal wall, even forming sinuses. Epididymitis does not have these characteristics.
4) Examination
1. Acute Epididymitis
Diagnosis is usually straightforward based on medical history and physical examination, but it must be differentiated from testicular torsion. Testicular torsion occurs suddenly, with the testis swollen, fixed, and unable to move within the scrotum. Elevating the scrotum does not relieve local pain.
2. Chronic Epididymitis
Chronic epididymitis is characterized by uniform enlargement and hardness of the epididymis, with tenderness.
5) Treatment
To maximize the preservation of fertility, treatment must be thorough. Antibiotics that easily diffuse into the male reproductive tract, such as erythromycin, doxycycline, and clindamycin, should be used. After acute symptoms subside, medication should continue for 4–5 days, and for chronic cases, treatment should extend for 2–4 weeks to consolidate the effect. Effective measures include elevating the scrotum, local cold compresses, abstinence from sexual activity, avoiding alcohol, spicy foods, and preventing congestion. The prognosis is better than epididymal tuberculosis, but if not treated thoroughly, it can persist long-term. Ultimately, scar formation may block the ducts, leading to infertility. If recurrent abscesses form, epididymectomy may be performed. If both epididymides are removed, fertility cannot be preserved.
1. Acute Epididymitis Treatment
Acute epididymitis requires adequate rest, antibiotics, and general analgesics. Local heat, physical therapy, and scrotal support can be applied. If an abscess forms, drainage is necessary. The underlying cause should also be addressed.
2. Chronic Epididymitis Treatment
Chronic epididymitis often coexists with chronic prostatitis, so treatment is similar to that for chronic prostatitis. Treating prostatitis can alleviate symptoms of chronic epididymitis. After healing, residual epididymal nodules may cause psychological burden, but surgical removal does not always relieve symptoms, so orchiectomy is generally not performed. For male infertility due to bilateral epididymitis, anastomosis at the proximal obstruction of the vas deferens and epididymis may partially resolve sperm drainage issues, but postoperative pregnancy rates remain low.
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