[Question #2913] Epididymitis after chlamydia treatment.

41 months ago
I was diagnosed with chlamydia a month ago shortly after a sexual encounter, and was given a 1g dose of azythromycin for treatment. At the time my only symptom was a very slight amount of discharge. The symptoms cleared up quickly and within a week I was back to normal.

Two weeks later I had sex with a new partner and within a day or two I started to experience a constant aching behind one of my testes. I went back to the doctor and was told it was epididymitis, likely caused by some lingering "remnants" of the infection. I was retested and prescribed a week's cycle of doxyciline as remedy. The doxyciline seemed to repress the epididymitis while I was taking it, but as soon as I stopped the dull but noticeable pain came back. It comes and goes throughout the day seemingly affecting either one or both testicle areas. Meanwhile the follow-up STD panel came back negative for everything.

I am wondering what could be the cause and correct treatment of my epididymitis. Is it really a"remnant" of chlamydia even though I seem to have cleared it? If so why didn't the doxycycline eradicate the symptoms, and what can I try differently? 

Another detail worth noting is that I did have unprotected anal sex with the latter partner (insertive, female) on the occasion just before the epididymitis appeared. Is it possible that this is caused by enteric organisms from the anal and completely unrelated to the earlier chlamydia infection? If so how should I proceed and might a different treatment be in order?


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
41 months ago
Welcome to the forum. Thanks for your question and your confidence in our services. I'll try to help.

I am skeptical that you have (or had) epididymitis. There's really no way that it could develop as a result of "remnants" of a chlamydial infection treated 3-4 weeks earlier, especially since your symptoms cleared up so nicely after azithromycin. And it certainly could not persist after also receiving doxycycline for a week. Also, epididymitis doesn't cause rather diffuse, mild, or dull testicular pain of the sort I think you are describing. Epididymitis is almost always very clearly involves only one testicle, which is significantly enlarged and markedly tender to touch. And this is true both for direct STD causes (chlamydia, gonorrhea) and epididymitis that can be caused by enteric bacteria. And all these forms are generallly accompanied by obvious continued urethritis, i.e. painful urination and/or discharge, which now apparently are absent, right? I believe your symptoms are not due to any infection -- and the fact that they have come and gone, and didn't stay away after doxycycline, also supports a non-infectious diagnosis. 

So I am much more suspicious that your symptoms are due to genitally focused anxiety or the chronic pelvic pain syndrome (CPPS), sometimes considered a variant of non-infectious prostatitis. Google CPPS (spell it out) for information, including a very good Wikipedia article as well as information from the Stanford University dept of Urology. You might discuss these issues with your physician; or if symptoms continue and/or she doesn't seem up to speed on these issues, ask for referral to a urologist. You could print out my comments as a framework for discussion.

But in the meantime, don't be worried. CPPS or prostatitis are pretty much harmless, both for affected men and their sex partners; and in general the symptoms just fade away with time.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD
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41 months ago
Thank you for the information.  Like you, I am skeptical that the issue is related to the chlamydia infection.  However I will note that I have run across numerous anecdotal cases on message boards of men experiencing testicular pain for weeks and months after successful chlamydia treatment.

I do still wonder whether it was caused by the latter sexual encounter. The symptoms began almost immediately after this contact and have persisted since. So it just seems like it might be related.  Is it worth getting checked out for e. coli or other enteric organisms that may have resulted from the anal sex, or asking the doctor for additional treatment just in case? Are there tests for this?  Some of the research I have done indicates that epididymitis caused by enteric organisms may not be treatable with doxyciline, but rather other antibiotics such as ofloxacin or maybe Cipro, etc. (Of course, you're the expert not me.)

And I will clarify that the pain I feel has indeed mostly affected the same single testicle over the whole time, in a specific area that feels like it is kind of behind the testicle itself. Sometimes the discomfort seems to spread to both but not usually. 

I will certainly research the other possibilities you have mentioned. I just wanted to hash out the above a little more since the timing of the anal sex and the onset of my symptoms pretty starkly coincide...


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
41 months ago
The worst possible evidence for an association of atypical symptoms with atypical causes is testimony on the web by affected persons. The small minority who had chlamydia and then had such symptoms are the ones who typically will go to the effort to seek others with similar problems, search the internet, and post their experiences. The vast majority of infected people, without such symptoms or with no perceived association with a particular cause, are entirely unrepresented. There is neither epidemiologic evidence nor any scientific reason to believe in such a thing -- i.e. no "biological plausibility".

That said, I agree the more localized sort of testicular pain you describe should be considered. But I still strongly doubt an infectious explanation. I don't doubt the association with the sexual encounter and/or chlamydia. But that doesn't mean it's due to a continuing infection of any kind. It is true that some enteric bacteria are not sensitive to doxycycline, but the large majority of such infections would respond to it. And your symptoms really are not all that suggestive. See my comments above about epididymitis pain, tenderness, etc -- and in the many cases of bacterial epididymitis I have seen over the years following insertive anal sex, every one not only had obvious, overt testicular pain and swellling, but all also had obvious urethral discharge with pus and more than just mild painful urination. (Physicians with lots of STD clinic experience often joke -- and like all jokes, there's an important element of truth -- that the guys with epididymitis could be picked out by the way they walked into the exam room, because of the marked pain in one testicle.)

Of course we cannot make any particular diagnosis online, nor can I rule out any particular explanation; we don't practice medicine from this distance. But based on all you have said, and the treatments you received, I remain confident you don't have infective epididymitis. However, testing for enteric infection is easy:  just speak with your doctor about a routine urinalysis and urine culture, to test for the common causes of urinary tract infection (which includes enteric bacteria).

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41 months ago
Thank you again for the response.  I did look into both CPPS and genitally focused anxiety.  I was actually surprised at the accepted legitimacy of the latter.   I will admit that I am currently going through some transitions in life that have added some more pressures and stressors than usual; and that's before we even consider the recent chlamydia fiasco.  So if it is true that stress and anxiety alone could trigger the symptoms I am having, then it would not be unreasonable to expect it now.  As an aside I will also note that I was told my blood pressure registered unusually high the two times I went to the doc for the above issues.  All that said, I am certain the pain I am experiencing is physical and not a mental construct or an imagined hypersensitivity.  It aches.  Just not bad enough to make me walk funny!

Are you confident enough in my current ailments being due to some factor other than infection, that I should stop worrying about it and might forego making yet another doctor's appointment to address what is likely a non-treatable, non-serious problem?  If so, do you have some suggestions as to how I may be able to make it go away and get back to feeling normal?  Is there anything I should pay extra attention to as far as diet, exercise, masturbation habits, etc. while this is still going on?


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
41 months ago
You're a better judge than I can be, from this distance, about potential psychological origin of your symptoms. All I can say is that from my experience, that's the outcome in the large majority of men with similar problems. And whenever someone suspects (or comes to realize) his or her symptoms may have a psychological origin, usually s/he is right. So the additional information you provide is consistent.

Please note I never implied your pain is not "physical", i.e. real pain. So is the pain of tension headaches, for which anxiety and other psychological origins are accepted by everybody. And the explanation for pain may be prestty much the same:  increased tension in scalp and neck muscles, or increased tension in pelvic muscles (with pelvic or prostate pain often "visceral" in character and referred to -- i.e. felt in -- nearby body parts.

As noted above, we cannot give direct medical advice. But if you were my patient, and if there were no surprises in my physical examination or lab results, for most such men I would probably advise watchful waiting, i.e. sitting tight for several weeks; continuing (or resuming) normal sexual activity (without fear of harm to oneself or partners); and waiting at least several weeks before doing anything else. At that point, repeating urinalysis, cultures, etc might make more sense (if symptoms continue), but in most men they just fade with time, especially as it becomes apparent that no important harm is occurring or likely in the future. We all live with unexplained aches and pains -- back ache, brief nausea or abdominal pain, headache, the previously sprained ankle that still hurts despite apparent complete healing. Why should the genitals be different? Not all pain or other symptoms mean disease! In any case, I am confident there is no rational role for additional trials of other antibiotics in the absence of more clear evidence of an active infection. Of course get care right away if your symptoms significantly worsen or if other symptoms appear.

If/when you return to your doctor(s) about all this, consider printing out this thread as a framework for discussion.

I hope the discussion has been helpful. That concludes this thread. Take care and stay safe.

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