[Question #3839] Epididymitis

34 months ago
Hi,

I have been suffering with bouts of Epididymitis over the last 16 years. On average, I end up with the condition twice or so a year (always left side). I am at a loss to the cause, generally speaking I am symptom free 6 weeks after the condition arises. Ultrasound has picked up the swelling, but never found any underlying reason for why I would get so much re-occurrence. I have now reached a point where I feel I need to explore alternative diagnosis/treatment. My normal course of action is antibiotics (Doxy/Cipro/Trimethoprim) but I am becoming more and more suspicious that these are effective only due to their anti-inflammatory effects. I am also now getting stronger and stronger side effects from all three listed above. 

It is important to note that I have never had any bacteria show in urine, and STD tests have always been clear. Despite this, I do see a pattern between sexual activity and the epididymitis (for example, at one point I was symptom free for 4 years, then a week after unprotected sex, I felt the familiar twitch - once again i must stress STD test was clear.) On another occurrence, i felt the epididymitis paint come on immediately after ejaculation. 

My general question is, where do i go from here, but more specifically.... 

1) If I refuse further antibiotics, what are the risks if an infection IS the cause - what should i be looking out for? 
2) Any possible thoughts on how unprotected vaginal sex could be causing this (allergies to vaginal bacteria, fungus, ) 
3) What diagnostic tests can I turn to (should i not expect bacteria to be found in a semen culture)? 
4) My personal belief is that this is a muscular condition - the good 'stress' of sex leading to tension, turning into inflammation. Any thoughts as to the likelihood of this. If so, is there any particular anti-inflammatory that could be prescribed, or is OTC the safest bet. 

Thanks 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Welcome to the forum. Thanks for your question and your confidence in our services. You raise complex issues. If you'll bear with me, and perhaps with more information than you were seeking, I'm taking the opportunity for a blog-like reply that I can use for future questions as well as yours.

The first and perhaps most important thing is to be sure that you truly have (or have had) recurrent epididymitis. Testicular pain by itself never is sufficient to make the diagnosis; usually there is testicular enlargement and tenderness as well, and often abnormal imaging, e.g. by ultrasound. Confirmation typically also requires careful physical examination and, for infectious epididymitis, evidence of infection involving the urethra, urine, or prostate -- at least evidence of inflammation (elevated white blood cells) or a positive test for a pathogen known to cause epididymitis.  Recurrent testicular or scrotal pain, without the rest of it, generally is not epididymitis. I'm not suggesting you do not or did not have it, and my replies below assume the diagnosis has been accurate each time. If so, presumably you have been seeing a urologist. Feel free to discuss the following replies with him or her.

First, the only STDs know to cause epididymitis are gonorrhea and chlamydia, and these are easily diagnosed by proper testing. They would always have all the features described above. Almost always, only one testicle is involved; bilateral testicular pain usually has other causes. And really, that's my only expertise. I have some general knowledge about other causes, but not in that much detail.

Other infectious causes of epididymitis include all the bacteria that sometimes cause urinary tract infections. The most common overall is E. coli, but other enteric (fecal) bacteria also are fairly common, and occasionally certain strains of staph or strep. Any of these can set up chronic infections in the prostate, without symptoms, from which infection can then spread from time to time to other parts of the urinary tract, including the epididymis. As for the STDs, usually any of these would cause only one sided epididymitis.

Tuberculosis and certain fungal infections also are possible. Viral infection, especially mumps, can do it, although not recurrent epididymitis.

Finally, there are non-infectious causes of epididymitis. Certain drugs can cause it as a side effect. Varioius immunologic conditions also are possible. This the area I know least about. However, most truly recurrent epididymitis probably falls into this category. From your description, and assuming you truly have had recurrent epididymitis, I suspect your problem falls into this category. To your specific questions:

1) In absence of a documented bacterial infection, it probably is safe to not use antibiotics. But you should discuss each such episode with your own doctor(s).

2) I cannot imagine any way in which unprotected sex per se could cause epididymitis. An immediate association of symptoms with sex suggests a psychological origin of those symptoms.

3) I alluded above to the proper diagnostic tests:  urine WBC, tests for various bacteria, scrotal ultrasound, etc. Again, something to address with your doctor, preferably a urologist.

4) I think these comments are very insightful. Certainly the first part of your statement makes sense, i.e. pain resulting from muscular tension. Perhaps you don't have epididymitis, but the chronic pelvic pain syndrome (CPPS), sometimes previously called nonspecific or non-bacterial prostatitis (but the prostate itself may not be involved). The discomfort of CPPS is believed to result from increased pelvic muscle tension (similar to neck and scalp muscle tension being the cause of pain in tension headache). However, CPPS is not associated with any inflammation at all. If you have true inflammation, e.g. elevated WBC in urine, it's evidence of something more than CPPS. For more information, google CPPS (spell it out). The Wikipedia article is very good (although I haven't re-read it recently); and so is information you can find from the Stanford University Dept of Urology.

I have no particular advice about treatment with anti-inflammatory or other drugs. This depends a lot on the actual diagnosis.

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

HHH, MD
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