EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131

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Acute and Chronic Epididymitis

Mete Çek a,*, Laura Sturdza b, Adrian Pilatz b

a b
Department of Urology, Trakya University, School of Medicine, Edirne, Turkey; Department of Urology, Pediatric Urology and Andrology, Justus Liebig
University Giessen, Germany

Article info Abstract

Keywords: Epididymitis is a relatively common clinical condition presenting as acute or

Acute epididymitis chronic forms. Acute epididymitis is the inflammation of epididymitis accompa-
Chronic epididymitis nied by pain and swelling, while chronic epididymitis may present only with pain.
Chronic scrotal pain Etiological factors may be infectious or noninfectious, for example urinary obstruc-
Sexually-transmitted infections tion, drug induced, or idiopathic. Bacterial ascent through the urogenital tract is the
Epididymo-orchitis most common etiology in acute epididymitis, with Chlamydia trachomatis being
isolated in all adult age groups. Diagnosis is generally based on patient history,
symptoms, and clinical findings. Recent data indicate that sexually active patients
with acute epididymitis should be screened for sexually-transmitted diseases,
regardless of their age. Additional laboratory investigations and imaging may be
required for differential diagnosis with other intrascrotal conditions, particularly
Please visit www.eu-acme.org/ with testicular torsion. Although no evidence-based recommendations can be
europeanurology to read and given for the antimicrobial treatment of acute epididymitis, >85% of bacterial
answer questions on-line. strains causing acute epididymitis are susceptible to fluoroquinoles and third-
The EU-ACME credits will generation cephalosporins. Chronic epididymitis has not been investigated as
then be attributed thorough as acute epididymitis; however, the development and use of a symptom
automatically. index is promising in terms of achieving a widely-accepted standardization of
diagnosis and evaluation. A conservative approach may be beneficial; medical
treatment employing antibiotics, anti-inflammatory agents, pain medication, and
others are also being utilized without any evidence-based data. Spermatic cord
block with short-term and long-term acting agents as well as surgical treatment
including epididymectomy microdenervation of the spermatic cord are other
treatment alternatives in patients with chronic epididymitis.
Patient summary: In this article, we provide an update on the definition, epidemi-
ology, etiology, diagnostics, and therapy in terms of acute and chronic epididymitis.
# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Urology, Trakya University, School of Medicine, Rektörlüğü,

Edirne 22030, Turkey. Tel. +90 532 262 6032.
E-mail address: metecek@gmail.com (M. Çek).

1. Introduction infectious agents. The clinical picture of this inflammation is

epididymitis.
The epididymis is a coiled, tubular organ which is attached
to the testis. The functions of the epididymis include 2. Epidemiology
transport, maturation, and storage of sperm. The epididy-
mis may become the target of various inflammatory Epididymitis is a common clinical condition with incidence
conditions which may or may not be associated with rates ranging from 25 to 65 per 10 000 person-yr (Table 1).
http://dx.doi.org/10.1016/j.eursup.2017.01.003
1569-9056/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.
 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131
Table 1 – Overview on epidemiologic studies investigations epididymitis
Author Period Region Age (yr)
and 10 000 men
Koch et al (1980) 1977–1978 US All ages
Collins et al (1998) 1990–1994 US 18–50
Bohm et al (2009) 2001–2004 US 14–35
Nicholson et al (2010) 2003–2007 UK 15–60
Nickel et al (2005) 2004 Canada All ages
However, most of the data are derived from coded
diagnoses investigating largely different study populations.
In this context, acute epididymitis, chronic epididymitis
(CE), and recurrent epididymitis are not always strictly
separated. Nickel et al [1] reported that more than 80% of all
cases are chronic (defined as duration >3 mo). In summary,
the reported prevalence includes the following figures:
0.29% of ambulatory office visits in men <50 yr of age [2]
and <1% of men presenting to urology outpatient clinics
[1]. It is the most common cause of scrotal pain in adults in
the outpatients setting, reaching up to 600 000 cases/yr in
the US [3]. In children, the incidence of epididymitis was
found to be one per 1000 boys in a prospective, population
based study [4].
Acute epididymitis can occur at any patient age and
largely depends on the study population investigated
[5–7]. Two different studies on CE reported the average
age of patients as 49  15 yr (age range, 21–83 yr) and 41.1 yr
(18–78 yr) [1,8], while the median age of patients with chronic
scrotal pain was reported to be 34 yr (age range, 19–52) in
another study [9]. This indicates that acute and CE are both an
important issue in men within the reproductive ages.
3. Acute epididymitis
3.1. Definition
Acute epididymitis is the inflammation of the epididymis
accompanied by pain and swelling with symptoms lasting
<6 wk. This clinical picture usually develops within a few
days and is typically unilateral. Without adequate therapy a
further spread to the testis occurs within a couple of days.
This is why several authors use the term epididymo-orchitis.
3.2. Etiology/pathophysiology
Acute epididymitis can be related to different etiologies. The
generally accepted route of infection in epididymitis is the
ascent of microorganisms from the urethra. Already in
1927, Campbell [10] concluded that gonococcal epididymi-
tis arose as a result of pathogen ascent starting as urethritis
leading to epididymitis a couple of weeks later. Another
finding was that from patients with indwelling urinary
catheters bacterial pathogens could be isolated from the vas
deferens and were identical with those isolated from the
urine. The hypothesis was confirmed by studies investigat-
ing pathogens isolated simultaneously from the urine/
urethra and epididymis showing 84% identicalness [11–14].
Finally, the bacterial ascent model was underlined by
125
Incidence/yr Comments
40 Estimation, about 60% follow-up investigations
29 Consultations to general practitioners and urologists
37 Insurance data analysis, only first event
25 Consultations to general practitioners
65 Consultations to urologists; chronic epididymitis?
studies reporting an involvement of the prostate or seminal
vesicles by biopsy, ultrasound, or measuring prostate-
specific antigen changes [6,7,13].
However, the true incidence of bacterial origin in acute
epididymitis is unknown. Before the breakthrough of
identifying Chlamydia trachomatis as a major pathogen in
young patients, studies investigating the etiology reported
a high incidence of idiopathic cases with about 50% [15].
Nevertheless, important studies from the 80s and 90s still
reported on 30% idiopathic cases [11,13,16–18]. The
percentage of idiopathic cases could be clearly decreased
to 13% in a recent study by applying modern molecular
diagnostics including polymerase chain reaction analysis
[7].
The pathogenic spectrum is related to the depth of
microbiological investigations performed, as well as the
study population investigated. Traditionally patients with
epididymitis <35 yr were suspected to have a sexually-
transmitted disease (STD; eg, C. trachomatis) as an
underlying cause while patients >35 yr were believed to
have epididymitis caused by enteric pathogens (eg,
Escherichia coli) [17]. Unfortunately, this cut-off is still
present in international guidelines [3,19], whereas recent
studies clearly provide evidence that sexually-transmitted
infections (STIs) are not restricted to a specific age [7,16].
In addition, a systemic spread of viral pathogens appears
a plausible cause of epididymitis, since about 5% of patients
report a previous respiratory tract infection within the
previous 14 d before the development of acute epididymitis
[7]. However, studies on viral pathogens are scarce, but
indicate that mumps virus and enterovirus epididymitis
represent rare causative entities [4,7]. It is not conclusively
clarified, if the epididymitis is a result of a direct viral
infection or a postinfectious immunologic epididymal
reaction [4,7].
3.3. Symptoms and signs
The presenting symptoms are usually pain and swelling
[6,12]. In 96% of cases the epididymitis is unilateral
[5,16,18,20]. From the first symptoms to medical consulta-
tion on average 2–4 d pass by [6,7,11,21].
Typical physical signs include unilateral swelling and
tenderness of the involved epididymis. Swelling usually
starts at the cauda epididymis before it ascends and
involves the whole epididymis and finally reaches the
testis [10]. The clinical spectrum of acute epididymitis
ranges from mild epididymal tenderness to severe, febrile
systemic disease including urosepsis [6,7,22,23]. In a recent
126 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131
Table 2 – Clinical and laboratory findings in epididymitis
Positive urine culture (>10 000 cfu/ml)
Fever >38.5 8C
Erythema of the scrotal skin
Leukocytosis (white blood count >11 000/mm3)
CRP "
Urethritis (>4 white blood cells/hpf)
Involvement of the adjacent testis
hpf = high power field.
series of 237 patients with acute epididymitis, Pilatz et al [7]
reported fever, defined as body temperature >38 8C, to be
present in 27.0% of cases. Hongo et al [23] reported age over
65 yr, history of diabetes mellitus, and fever >38 8C to be
independent variables associated with severe disease in a
series of 160 patients with acute epididymitis. Clinical and
laboratory findings in epididymitis are summarized in
Table 2.
Interestingly, only 30% of patients report concomitant
dysuria [6,21], while the presence of typical urethritis
symptoms is much lower and largely depends on the study
population, with prevalence rates from 0% to 73%
[6,17,18,21]. Of note, patients suffering C. trachomatis
epididymitis are usually asymptomatic in terms of urethral
discharge [7].
In patients with mumps epididymo-orchitis, scrotal
swelling occurs in about 40% of patients 5–10 d after initial
parotitis and patients suffer typically unilateral a painful
and enlarged testis [24]. However, large epidemiologic data
evaluating several thousand cases in the area before
vaccination clearly showed that mumps primarily involves
the testis, while the epididymis is only secondarily affected
[25].
3.4. Diagnostic considerations
3.4.1. Medical history
A careful history is essential to detect possible comorbid-
ities and risk factors [26,27]. In addition, symptoms of
urethritis, history of urethral instrumentation, previous
scrotal surgery, previous episodes, and recent sexual
activity should be inquired. The sexual history is crucial,
since various studies could show that up to 37.5% of men
had multiple sexual partners in parallel [21], and up to 66%
of men below 35 yr of age reported new sexual contacts
within the previous 4 wk [21]. Further, sexual intercourse
with professional sex workers as well as homosexual
practices have to be considered [12,20]. Despite the
importance of the sexual history, it is only inquired in
about 50% of patients in the routine setting [26,28].
3.4.2. Physical examination
Patients should be examined for systemic signs like
tachycardia or fever, which may indicate severe disease.
Examination of the scrotum may reveal a tender
spermatic cord. The epididymis is tender and swollen; an
indurated cauda or the whole epididymis is frequently
palpable [7,10]. Testicular swelling may occur in the early
stage as well as later on [6,20]. Cremasteric reflex
(ipsilateral contraction of the cremasteric muscle resulting
in ipsilateral testis elevation) is present in early stages of
epididymitis. Prehn’s sign (relief of pain when the testes are
elevated) should also be evaluated. Thus, in cases with
isolated epididymitis palpation without ultrasound is
sufficient to establish the correct diagnosis [16]. Since
bacterial ascension is the major etiologic cause, a rectal
examination to exclude prostatic abscess formation might
be recommended [10].
3.4.3. Imaging
Ultrasound is the gold standard for the evaluation of scrotal
disease. In virtually all patients with acute epididymitis, an
epididymal enlargement associated with epididymal hyper-
perfusion can be detected [11,29]. Since most epididymitis
cases can be diagnosed on the basis of clinical findings
[6,16], scrotal ultrasound is not suggested in cases with
simple epididymal enlargement [3,16,29].
However, ultrasound is essential in severe cases,
persisting disease, or unclear findings when adequate
palpation is hindered by pain, scrotal wall induration, or
large reactive hydroceles [3]. Specifically, abscess formation
and secondary testicular infarction can easily be detected. If
a conservative therapy is chosen in severe cases, serial
investigations are recommended [29].
3.4.4. Microbiological analysis
Since bacterial ascension through the urogenital tract is of
major etiologic relevance, diagnostic studies are required to
confirm the infectious etiology and to detect the causative
pathogen. Urine analysis shows leukocyturia in up to 80% of
patients and a positive test on nitrite in 30% of patients
[6,16,30]. Current guidelines recommend urine culture and
susceptibility testing in all patients with epididymitis
[3,19,31]. In addition, STDs should be screened in at least
all patients with a sexual history or signs of urethritis
suggesting STDs. Even better would be to screen all sexual
active patients, since STDs are frequently present in patients
who did not report such risk [7].
Depending on the local facilities the urethritis diagnos-
tics on STDs can apply urethral smears or first void urine.
Possible procedures include a gram stain of urethral smears
to screen for Neisseria gonorrhoeae, cultures, or polymerase
chain reaction-based methods to detect N. gonorrhoeae,
C. trachomatis, and Mycoplasma species [3,19,31]. Patients
might be tested as well for other STDs, depending on the
individual risk [3]. However, only 30% of patients under the
age of 35 yr receive an adequate diagnostic when presenting
with symptoms of urethritis in the clinical routine [26,28].
Currently, no clear recommendations can be given
regarding postprostatic massage urine specimens for
microbiological investigations. However, microbiological
diagnostics on semen samples at the acute infection stage
is not recommended, because of pain and the low additional
benefit compared with adequate urine diagnostics [18,20].
Invasive procedures (eg, epididymal aspiration) are obsolete
because of the risk of obstruction. Only in cases where
surgical procedures are required (epididymectomy or
 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131 127

orchiectomy) an isolation of the pathogen from that
specimen should be aimed at in order to optimize
antimicrobial therapy in the recovery phase [7,27].
Finally, it is of utmost importance to perform all
microbiological investigations before starting any antimi-
crobial therapy, since afterwards a bacterial pathogen can
only seldom be detected [7,20,26].
beneficial to reduce unnecessary scrotal explorations
[33]. This concept has to be supported by the local
infrastructure. Specifically, any relevant delay (eg, waiting
for the radiologist) needs to be avoided to preserve
testicular function in case of torsion [33,34]. In addition,
investigators have to be experienced in scrotal ultrasound
to minimize the risk of misdiagnosis [36].

3.4.5. Laboratory investigations 3.5. Treatment

A systemic inflammation is regularly present in patients
depending on the severity of the local findings. While
leukocytosis has been described in only 20% of patients in
older studies, recent data indicate that leukocytosis is
common in about 70% of cases [7]. In addition, measurement
of C-reactive protein is helpful for disease confirmation and
monitoring [7,32]. In different studies mean C-reactive
protein levels were reported to be 60 mg/l [7,32]. When
applying a cutoff value of 20 mg/l, sensitivity and specificity
have been described to be each 95% to rule out testicular
torsion [32]. To date, a specific serum marker to confirm
epididymitis is not available.
3.4.6. Differential diagnosis
Differential diagnostic work up of acute epididymitis
includes testicular torsion, torsion of the appendix testis,
inguinal hernia, testicular carcinoma, painful varicocele,
scrotal abscess, phlegmon, acute orchitis, and testicular
trauma. Elimination of testicular torsion is the first step as
this condition is a surgical emergency [33].
Although patient’s age, medical history, clinical signs,
laboratory, and ultrasound findings normally allow a
distinction between different entities (Table 3) [32,34],
not uncommonly contrary constellation of findings occur
[30,35]. This explains the high rate of surgical exploration in
up to 60% in older studies, where ultrasound was not
available [5,14]. A pooled analysis of 20 studies published
after the year 2000 demonstrated a sensitivity of 90% and a
specificity of 97% to detect testicular torsion by ultrasound
[34]. Thus, the broad application of ultrasound was
Treatment should aim to cure infection while improving
symptoms. Thus, antimicrobial therapy is of utmost
importance. Historically, bed rest, scrotal elevation, and
local cooling were applied, since antimicrobials were not
available [10]. Although randomized studies are missing,
these recommendations are still widely applied. However,
adjuvant corticoid therapy as well as spermatic cord
infiltration have been abandoned due to a lack of efficacy
and the upcoming availability of nonsteroidal anti-inflam-
matory drugs for analgesia [11,37].
Patients can safely be managed on an outpatient basis.
Hospitalization will be limited to patients with multi-
morbidity, severe pain, high fever, or when patients are
noncompliant [3,7].
When utilizing adequate diagnostics and antimicrobial
therapy, surgical therapy is only rarely necessary and
includes mainly epididymectomy, orchiectomy, or both
[7]. These procedures should be limited to patients with
refractory epididymitis and those with secondary testicular
infarctions. While some authors suggest drainage of
epididymal abscess formation [22], a recent large study
showed epididymal abscess formation to resolve complete-
ly under conservative therapy [7].
3.5.1. Antimicrobial therapy
Antimicrobial therapy has to be chosen upon consideration
of the most probable pathogens and epididymal drug
penetration. Unfortunately, antimicrobial studies are rare.
In those, tetracyclines have demonstrated good results in

Table 3 – Differential diagnosis of acute epididymitis

Acute epididymitis Testicular torsion Appendix testis torsion

Duration of symptoms Few d Few h Few d

Pain intensity Moderate Severe Moderate
Age group All ages Adolescents, young adults Children
Swelling Epididymal cauda, High-riding, transversally Epididymal head
later on whole epididymis oriented testis
and/or testis
Nausea/vomiting Uncommon Possible Uncommon
Cremasteric reflex Present in mild forms Usually absent Present
Testicular position Normal Abnormal axis Palpable nodule
Abnormal elevation Blue dot sign
Prehn’s sign Relief of pain (= positive) Exacerbation of pain (= negative)
Discharge or urinary symptoms Common Rare Rare
Tenderness Local, then diffuse diffuse Local, then diffuse
Fever Possible No No
Pyuria Common Uncommon Uncommon
Leukocytosis Common Uncommon Uncommon
Perfusion in ultrasound Increased in epididymitis Absent or decreased Normal or increased
intratesticular flow epididymal head perfusion
128 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131
patients with suspected C. trachomatis involvement [11]. A
clear advantage was the medication with fluoroquinolones
starting in the 1980s, because of their efficiency against
both C. trachomatis and common urinary pathogens [14]. In
the only randomized controlled trial ciprofloxacin was
clearly superior to pivampicillin with reported clinical
failure rates of 20% and 40%, respectively [16]. These data
are the basis of the current Centers for Disease Control and
Prevention and European association of Urology guidelines’
recommending fluoroquinolones with activity against
C. trachomatis as first choice, except in cases with
N. gonorrhoeae [3,19]. A recent study confirmed the
recommendations reporting that >85% of bacterial strains
are still susceptible despite increasing antimicrobial resis-
tance rates worldwide to both fluoroquinolones and third-
generation cephalosporins [7]. However, no evidence-based
recommendations can be given for how long the antimi-
crobial therapy should be given.
In patients with confirmed STIs, the therapy of sexual
partners is mandatory to prevent reinfection and spread of
STIs [18,21].
4. CE
4.1. Definition
CE is defined as ‘‘symptoms of discomfort and/or pain in the
scrotum, testicle, or epididymis, localized to one or each
epididymis on clinical examination’’ [3,9,38]. Centers for
Disease Control and Prevention definition requires a period
of 6 wk for the duration of symptoms, while others accept
a period of 3 mo with symptoms, relating this condition
with chronic orchalgia [8].
4.2. Etiology/pathophysiology
Various etiological factors have been held responsible for
the development of CE. Among these are inflammation,
infection, and urinary obstruction [38]. However, the
etiology cannot be identified in many patients. Strebel
et al [9] suggested that postinfectious alterations/inflam-
matory reactions rather than ongoing bacterial infections
play a major role in the etiology of CE.
Granulomatous reaction, particularly tuberculosis, is one
of the frequent causes of infectious CE. Intravesical
instillations of Bacillus Calmette–Guérin can also induce
CE [39]. Sarcoidosis, brucellosis, and other causes of
granulomatous epididymitis are infrequent.
Nickel et al [8] performed a survey to describe the main
characteristics of patients with CE which revealed that
certain conditions seem to be associated with CE: (1) having
more sexual partners, (2) less often usage of STD protection,
(3) general self-reported musculoskeletal, neurologic, and
infectious and/or inflammatory medical problems, includ-
ing a history of urinary tract infections, and depression,
compared with men without this condition. However, these
differences did not reach statistical significance. Of interest,
a history of vasectomy did not have a major association with
CE in this survey [8].
Epididymitis induced by drugs (eg, amiodarone) as well
as associated with generalized diseases (eg, Behçet’s
disease) have also been described in medical literature
[40,41]. CE occurring after vasectomy has been described
and is suggested to be associated with obstruction as a
potential cause of chronic pain [42]. Finally, idiopathic cases
are not uncommon.
4.3. Clinical presentation and classification (symptoms and
signs)
Patients with CE, by definition, have at least 6 wk or longer a
history of discomfort or pain in the epididymis. The
epididymis may be felt normal or abnormal on physical
examination. In addition, patients may experience testicu-
lar pain. While an infectious cause can be documented in
some patients with CE, there are patients without any signs
of infection. Obstruction due to vasectomy and reflux of
urine into the ejaculatory ducts are two main causes of
noninfectious CE [43,44]. CE has a negative impact on the
quality of life, being sometimes associated with depression
[8].
Tuberculous epididymitis has a rather subacute onset;
swelling of the epididymis may or may not be painful.
Systemic symptoms, scrotal thickening, and fistula may
accompany tuberculous epididymitis [45].
After evaluating clinical features in 50 patients with
chronic epididymitis, Nickel et al [8] have developed a
classification for chronic epididymitis, aiming to provide a
useful tool for future clinical studies [8] (Table 4).
4.4. Diagnostic considerations
4.4.1. Medical history
A thorough history is essential. The location, severity, and
frequency of epididymal/scrotal pain as well as potential
exacerbating activities/factors should be inquired. Particu-
larly noninfectious epididymitis can be incited by pro-
longed periods of sitting or vigorous exercise.
History of previous urinary tract infection, scrotal
surgery (eg, vasectomy), and sexual history should be
carefully inquired [8].
4.4.2. Chronic Epididymitis Symptom Index
Nickel et al [1] have developed a Chronic Epididymitis
Symptom Index to provide a standard for the evaluation of
patients with CE as well as guiding/comparing future
Table 4 – Classification of Chronic Epididymitis (CE) [38]
1) Inflammatory CE where the patient expresses pain and discomfort while
the epididymis is swollen and indurated.
a) Infective (eg, chlamydia)
b) Postinfective (eg, after acute bacterial epididymitis)
c) Granulomatous (eg, tuberculosis)
d) Drug-induced (eg, amiodarone)
e) Associated with a known syndrome (eg, Behçet’s disease)
f) Idiopathic (ie, no identifiable etiology of inflammation)
2) Obstructive CE (eg, following vasectomy)
3) Chronic epididymalgia
 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131 129

clinical trials. This symptom index has two questions about
the severity of symptoms and three questions in the domain
of quality of life. Pain scores range between 0 and 15, while
quality of life impact scores vary between 0 and 12,
resulting in a total score between 0 and 27. Wide acceptance
and application of this symptom index may help investi-
gators to achieve standardized evaluation and treatment
protocols for the management of CE. The mean symptom
score of patients with CE was reported to be 15.5.
one-fourth of these patients receive pain medication
[38]. Unfortunately, these treatment modalities have not
been compared in randomized, placebo controlled trials, to
date. Patient-specific, tailored treatment regimens utiliz-
ing combinations of these modalities may be useful.
Unresponsive patients may benefit from spermatic cord
block with lidocaine. Encouraging results have been
obtained with onabotulinum toxin A injections which
provide long lasting pain reduction (3–6 mo) [48].

4.4.3. Physical examination 4.5.3. Surgical treatment

Physical examination should include careful examination of
the scrotum as well as the lower abdomen and prostate. The
presence of any induration on the epididymis and the testis,
location of pain, any irregular finding on the spermatic cord,
and signs of inflammation should be noted [8].
4.4.4. Laboratory tests
Initial laboratory analysis should include a urinalysis and
midstream urine sample for culture. Further investigations
should be tailored individually, such as STD screening in
patients with urethral discharge and two/four glass test in
patients with symptoms compatible with chronic pelvic
pain syndrome [38,46].
CE may also induce changes in semen parameters which
include a decrease in sperm count and motility as well as
significant changes in sperm functions. These changes
include atypical staining of flagella, disturbed DNA integrity,
increased granulocyte elastase, and decreased a-glucosidase
[47].
4.4.5. Differential diagnosis
Differential diagnosis of CE should be made with hydrocele,
tumors of the testis and epididymis, painful varicocele, and
chronic pelvis pain syndrome.
Unfortunately, randomized controlled trials comparing
surgical treatment (epididymectomy) with other modalities
are lacking in this area. Various investigators evaluated the
results of epididymectomy in a series of 16 to 53 patients
with follow-up periods varying between 1 mo and 7.4 yr.
Postoperative pain-free rates are reported to be between 5%
and 59% [42,46,49]. Success rates are not strikingly different
between postvasectomy or nonvasectomy series, although
better results are obtained in the latter group [50]. Based on
the published series, Laurence and Levine [50] reported that
palpable painful epididymis and tender cystic lesions
isolated to the epididymis predict good results after
epididymectomy, while normal structural findings on
physical examination and on ultrasonography predict
unsuccessful results. The outcome of epididymectomy in
patients with CE are summarized in Table 5.
Microdenervation of the spermatic cord (MDSC) is a
surgical treatment modality which is performed in patients
not responding to any of the above-mentioned therapies.
After receiving successful results with spermatic cord block,
Table 5 – Outcomes of epididymectomy in patients with chronic
epididymitis

Author No. patients Results

4.4.6. Imaging undergoing
Doppler ultrasound imaging of the scrotum may be useful if epididymectomy
the physical examination findings of an indurated epididy-
Davis (1990) 10 Relief only in one patient
mis require differential diagnosis with an epididymal and/ Davis & Noble Partial relief in 27% with
or testicular tumor as well as suspicion of painful varicocele. (1993) inguinal orchiectomy
Chen & Ball 24 Benefit reported by 15 patients
(1991)
4.5. Treatment
Padmore et al 27 92% with epididymal cyst
(1996) satisfied
4.5.1. Conservative treatment 43% with epididymalgia
Patients with mild symptoms can be observed without any satisfied
West et al 16 14 pts with initial benefit
intervention. In this case, the patients should be reassured (2000)
that the condition is benign in nature, and the clinical Hori et al 53 No pain in 93.3% in
symptoms may fade away in time. Some patients in this (2009) postvasectomy group
group may benefit from conservative measures like scrotal No pain in 75% in nonvasectomy
group
support and local heat. Patients can be advised to avoid Sweeney et al 38 Resolution of symptoms in 32%
certain activities that seem to aggravate CE symptoms. (2008)
Calleary et al 32 Excellent results in patients
(2009) with structural abnormalities
4.5.2. Medical treatment
55% chance of improvement in
Due to the lack of evidence-based data for the treatment of patients with normal findings
CE, various modalities have been employed by clinicians. Siu et al (2007) 34 70% reported no pain
Among these are antibiotics, anti-inflammatory agents, Sweeney et al 29 Outcome satisfactory in 27/29;
(1998) best results in the vasectomy
phytotherapy, anxiolytics, narcotic analgesics, acupunc-
group
ture, and injection therapy (steroid or anesthetic). Around
130 EUROPEAN UROLOGY SUPPLEMENTS 16 (2017) 124–131
all structures that may be carrying neural fibers are divided
while the arteries (testicular, cremasteric, and deferential),
lymphatics, and the vas deferens are preserved [50]. After
reviewing eight reports on MDSC (204 patients, 2- mo
follow-up), Laurence and Levine reported that 83% of
patients achieved a pain-free status while 12% improved.
The major advantage of MDSC is the possibility of sparing
the testicle.
Prevention of adhesion with the use of concurrent
administration of the inhibitors of adhesion and fibrosis
hyaluronic acid and carboxymethylcellulose are reported to
be useful to improve the outcome of epididymectomy [44].
Conflicts of interest
The authors have nothing to disclose.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
eursup.2017.01.003.
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