Conservative Therapy
Many urologists suggest watchful
waiting for patients in whom symptoms
are mild and/or transitory.
Empathy and reassurance (particularly
that the pain and/or induration of
the epididymis does not represent a
cancer) is all some patients require. If
future studies determine the natural
history of this condition, we may
be able to reassure some patients
that it is a condition that “burns out"
over time. Scrotal support, local heat
therapy, and avoidance of aggravating
activities may also be useful
suggestions.
Medical Therapy
Medical treatment regimens for
patients with chronic epididymitis
VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY 213
Careful examination of the scrotum and contents will determine the location
of pain and any association with induration, inflammation, or
masses within the spermatic cord, epididymis, and/or testicle.
214 VOL. 5 NO. 4 2003 REVIEWS IN UROLOGY
Chronic Epididymitis continued
are essentially nonexistent. Published
studies examining other potential
treatment modalities are also sparse
and usually describe surgical outcomes
(epididymectomy) in these
patients. 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. This small series
probably represents the most common
therapies employed by primary
care physicians. It is probable that
urologists use a similar medical
treatment plan but also consider epididymectomy
if the case is refractory
to medical therapy. To our knowledge,
there are no good prospective
studies evaluating these therapies in
patients with chronic epididymitis.
Surgical Therapy
There are more data related to the
potential benefits of epididymectomy
in patients with chronic epididymitis
and epididymo-orchitis. In the 89
patients identified with chronic or
recurrent epididymitis in Mittemeyer
and colleagues’ armed forces study,6
61 underwent epididymectomy and
eventually returned to active duty.
Davis and colleagues1 reported a
clinical series of patients with chronic
orchalgia, although many appeared
to have at least an associated diagnosis
of chronic epididymitis. Thirtyone
patients underwent surgical
therapy (orchidectomy [n = 24], epididymectomy
[n = 10], orchidopexy
[n = 5], or hydrocelectomy [n = 1])
and, based on this experience, the
authors recommended inguinal
orchidectomy as the procedure of
choice for testicular pain when conservative
measures were unsuccessful.
In this study, only 1 of the 10
patients treated with epididymectomy
had significant pain relief.
In a series reported by Chen and
Ball,12 epididymectomy successfully
ameliorated pain symptoms in 5 of
10 patients with postvasectomy epididymal
pain, 6 of 7 with epididymoorchitis,
and 4 of 7 with epididymal
pain associated with an epididymal
cyst. Padmore and colleagues18
described a series of 27 men who
underwent epididymectomy after
empiric long-term and repeated
courses of antibiotics and/or antiinflammatory
agents had failed, and
reported patient satisfaction to be
extremely high in the epididymal cyst
group compared with the epididymitis/
epididymalgia group (92% vs 43%).
West and colleagues13 performed
19 epididymectomies (bilateral [n = 3]
and unilateral [n = 13]) in 16
patients who suffered pain after
vasectomy. Of the 16 patients, 14 were
reported to have excellent initial
symptomatic benefit from epididymectomy.
Long-term follow-up in 10
patients suggested that the benefits
were durable. Poor outcome was predicted
in patients with atypical
symptoms, including testicular or
groin pain, erectile dysfunction, and
normal appearance of the epididymis
on ultrasound.
Conclusion
Chronic epididymitis is a common
clinical entity diagnosed and treated
by practicing urologists but essentially
ignored by academic urologists.
Main Points
• Chronic epididymitis can be defined as symptoms of discomfort and/or pain at least 3 months in duration in the scrotum, testicle,
or epididymis localized to one or each epididymis on clinical examination.
• No effort has been made to determine the incidence or prevalence of this common condition; however, it must have significant socioeconomic
impact, because the men affected, on average, are in the most productive years of their lives.
• The etiology of chronic epididymitis can be associated with inflammatory, infectious, or obstructive factors but, in many cases,
no identifiable etiology can be identified.
• The Chronic Epididymitis Symptom Index, developed for a recent, prospective, case-control study, is a validated symptom index
that can serve in baseline evaluation and follow-up of patients with chronic epididymitis, both in clinical practice and research
treatment trials.
• Many urologists suggest watchful waiting for patients in whom symptoms are mild and/or transitory. Judging from the case-control
study (see above point), the most common medical therapies for chronic epididymitis are antibiotics and anti-inflammatory agents;
less common are phytotherapy, anxiolytics, narcotic analgesics, acupuncture, and injection therapy.
• Several studies report varying results with epididymectomy for patients with epididymitis in whom conservative and medical
therapies have failed. In one study of 16 patients who suffered pain after vasectomy, 14 were reported to have excellent initial
symptomatic benefit from epididymectomy.
Chronic Epididymitis
It is important for the urologic community
to determine the incidence
and prevalence, further describe the
demographic associations, and determine
the socioeconomic costs associated
with this condition. It would be
helpful to calculate the etiology and
pathogenesis of this condition by
applying the same scientific rigor
that is presently being employed in
the evaluation of the etiology and
pathogenesis of prostatitis and interstitial
cystitis.
Finally, practicing urologists would
benefit greatly from prospective
treatment trials, evaluating the most
common treatments employed (antibiotics,
anti-inflammatory agents, and
surgery) for this condition. A start
has been made with the development
of a definition of the syndrome, a
classification system that may prove
useful in clinical practice, and a
symptom index that can be employed
not only in clinical practice but also
in prospective treatment trials.
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