Chronic Epididymitis: A Practical Approach to Understanding and Managing a Difficult Urologic Enigma

Chronic Epididymitis: A Practical Approach to Understanding and Managing a Difficult Urologic Enigma
J. Curtis Nickel, MD, FRCSC
Department of Urology, Queen’s University, Kingston, Ontario, Canada
Rev Urol. 2003 Fall; 5(4): 209–215.
PMCID: PMC1553215
Copyright © 2003 MedReviews, LLC

Abstract
Many patients with unilateral or bilateral testicular, epididymal, or scrotal pain as their sole presenting symptom receive a diagnosis of “chronic epididymitis.” This common clinical entity is diagnosed and treated by practicing urologists but essentially ignored by academic urologists. This article defines chronic epididymitis, reviews current knowledge regarding its etiology, and describes appropriate physical examination and clinical testing for patients with the condition. The recently developed Chronic Epididymitis Symptom Index is presented, which can be used for baseline evaluation and follow-up of patients with chronic epididymitis, both in clinical practice and in research treatment trials. Treatment options, from watchful waiting to medical therapy to epididymectomy, are reviewed.

Key words: Epididymitis, Scrotal pain, Testicular pain, Epididymectomy
The Patient with Chronic Epididymitis: A Prospective Study
Definition of Chronic Epididymitis
Epidemiology

This study shows how poorly researched chronic epididymitis is. Since very little is known about etiology, and diagnostic tests are not up to par, good treatments are often not available. The author actually calls epididymitis a "...common and important, but neglected, urologic diagnosis."

This study also says, "In a comprehensive demographic analysis, compared with control patients, men diagnosed with chronic epididymitis had more sexual partners, used sexually transmitted disease protection less often, and had a higher incidence of past sexually transmitted disease. Patients with chronic epididymitis had more general self-reported musculoskeletal, neurologic, and infectious and/or inflammatory medical problems, including a history of urinary tract infections, than did men without this condition. Depression appeared to be a major problem in patients presenting with chronic epididymitis. Surprisingly, a history of vasectomy did not have a major association with a diagnosis of this condition (see Etiology, below), but that could be because this was a small, case-control study."

So what causes epididymitis? The author says:

"No comprehensive attempt has been made by past researchers to determine the etiology and pathogenesis of chronic epididymitis. Based on experience and our review of the literature, we would suggest that the etiology of this condition can be associated with inflammatory, infectious, or obstructive factors; however, in many cases, no etiology can be identified. There is some evidence that chronic epididymitis may be infective (eg, chlamydia⁷) and, although there are no studies to confirm this, there seems to be a postinfective chronic epididymitis (ie, after an episode of acute bacterial epididymitis, the inflammation and discomfort persist). Granulomatous epididymitis (eg, tuberculous or bacillus Calmette-Guérin) has been well described.^8,9 Drug-induced epididymitis (eg, amiodarone) is also a well-recognized entity,¹⁰ as is chronic epididymitis associated with other generalized diseases (eg, Behçet’s disease).¹¹ However, many patients present with an inflammatory type of epididymitis (pain and/or discomfort associated with inflammatory swelling and/or induration of the epididymis) for which no identifiable etiology is apparent.

Chronic epididymitis can be associated with obstruction distal to the epididymis (eg, vas deferens). It has been well described as occurring after vasectomy^12,13 and can also be seen in patients with congenital abnormalities of the lower urinary tract.

Many patients, however, present with chronic pain and/or discomfort of varying intensity associated with a normal epididymis that can sometimes be exquisitely tender on palpation. Often, these patients have no identifiable etiology for the pain (although it is tempting to believe that these patients may have a neuropathic type of epididymal pain)."

In short, the doctors often do not know.
So, how are these patients treated?
The authors say:

"The most common previous therapies recollected by the patients in our published case-control study² were antibiotics (74%), anti-inflammatory agents (36%), phytotherapy (16%), anxiolytics (12%), narcotic analgesics (10%), acupuncture (8%), and injection therapy (steroid or anesthetic) (6%). At the time of the survey, about one fourth (26%) of the patients were taking some type of pain medication."

There is a serious deficiency of prostatitis research. With the help of activists who follow this website, we will try to do something about this situation.

The author has developed a symptom score for epididymitis and we will look into that soon for our followers.