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Health condition · Clinically reviewed

Epididymitis, rule out torsion, then treat the right cause.

Unilateral scrotal pain and swelling with fever or dysuria - a common infection that responds well to the right antibiotic, once torsion is excluded.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against BASHH, EAU and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including scrotal Doppler, NAAT testing and stewardship-led antibiotic choice.

Key facts

Epididymitis at a glance.

The essentials in plain English - what it is, who gets it, and how UK clinicians decide between an STI, a urinary infection and something more serious.

  • What it is

    Inflammation of the epididymis - often extending to the testis (epididymo-orchitis) with unilateral scrotal pain, swelling and tenderness.

  • STI-related under 35

    Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium are the leading causes in sexually active men under 35.

  • Urinary in older men

    Over 35, coliforms such as E. coli, Klebsiella and Enterococcus dominate - often linked to BPH, retention or catheterisation.

  • Viral causes

    Mumps orchitis is the classic viral pattern - COVID, EBV and CMV can also inflame the epididymis or testis.

  • Critical differential

    Testicular torsion is a surgical emergency and must be excluded first - sudden severe pain and a high-riding testis are red flags.

  • First test

    Scrotal Doppler ultrasound - increased flow supports epididymitis, absent flow points urgently to torsion.

Why this guide matters

Three decisions that shape recovery.

Epididymitis is treatable, but getting the first three decisions right - exclude torsion, target the likely pathogen, complete the course - is what separates a full recovery from chronic pain.

  • Exclude testicular torsion first

    Sudden severe pain in a young man is torsion until proven otherwise - a surgical emergency needing immediate urology and Doppler ultrasound.

  • Match the antibiotic to the cause

    STI cover for men under 35, coliform cover for older men and those with urinary risk - guided by BASHH, EAU and MSU sensitivities.

  • Finish the course and follow up

    Ten to fourteen days of the right antibiotic prevents abscess, chronic epididymalgia and infertility. Persistent lumps need imaging.

How the diagnosis is made

From first pain to a clear diagnosis.

The steps a UK GP, GUM clinician or urologist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and risk profile

    Sexual history, urinary symptoms, catheter use, mumps exposure and occupational risks such as brucellosis or tuberculosis.

  2. 02

    Assessing

    Scrotal examination

    Tender epididymis, scrotal wall erythema, Prehn sign and cremasteric reflex - all recorded but none reliable enough to exclude torsion alone.

  3. 03

    Assessing

    Exclude testicular torsion

    Sudden severe pain, a high-riding testis or absent cremasteric reflex trigger emergency urology and immediate Doppler ultrasound.

  4. 04

    Confirming

    Urine, MSU and NAAT

    Urine dip and MSU for bacterial infection - first-void urine NAAT for chlamydia and gonorrhoea in men under 35 or with STI risk.

  5. 05

    Confirming

    Scrotal Doppler ultrasound

    Confirms epididymitis (increased flow), rules out torsion (reduced or absent flow) and identifies abscess, hydrocele or a suspicious testicular mass.

  6. 06

    Confirming

    Full STI screen and bloods

    HIV, syphilis and hepatitis screen alongside FBC and CRP - mumps IgM if orchitis is suspected without a bacterial source.

  7. 07

    Referring

    Urology and GUM referral

    Specialist urology for older men, recurrent disease or suspected obstruction - GUM/BASHH pathway for STI-related infection and partner notification.

Typical timeline: from first visit to a settled plan within 24 to 48 hours.

Symptoms

What epididymitis actually looks like.

A subacute picture of unilateral scrotal pain, swelling and tenderness - often with fever, dysuria and urethral discharge. And the features that mean it might be torsion.

  • Unilateral scrotal pain

    Subacute onset over hours to days - dull, aching then sharper as swelling develops.

  • Tender, swollen epididymis

    A firm, tender ridge behind the testis - the hallmark finding on gentle scrotal examination.

  • Scrotal erythema and warmth

    Overlying skin becomes red, hot and thickened as inflammation intensifies.

  • Fever and systemic upset

    Rigors, malaise and low-grade fever - more common with urinary pathogens and severe disease.

  • Dysuria and urethral discharge

    STI-related epididymitis often carries urethritis - burning on passing urine and clear or purulent discharge.

  • Prehn sign

    Relief with scrotal elevation suggests epididymitis over torsion - useful but unreliable, never used alone.

  • Reactive hydrocele

    A tense, fluid-filled sac can develop alongside inflammation and may need imaging to distinguish from abscess.

  • Red flag - torsion pattern

    Sudden severe pain, a high-riding testis and an absent cremasteric reflex in a young man is a surgical emergency.

Treatment

How epididymitis is treated in the UK.

Empirical antibiotics tailored to age and likely pathogen, supportive care, drainage of any abscess, partner notification and a chronic pain pathway when needed.

  • Ceftriaxone plus doxycycline

    BASHH first-line for men under 35 or with STI risk - a single 500 mg IM dose of ceftriaxone with doxycycline 100 mg twice daily for 10 to 14 days.

  • Ciprofloxacin or co-amoxiclav

    For likely urinary pathogens - a 10 to 14 day course guided by local antimicrobial stewardship and MSU sensitivities.

  • Intravenous antibiotics

    For septic or systemically unwell patients - admission for IV therapy, close monitoring and imaging to exclude abscess.

  • Scrotal support and rest

    A supportive athletic support, bed rest for a few days, ice packs and adequate hydration ease pain and swelling.

  • NSAIDs and paracetamol

    Ibuprofen or naproxen with paracetamol - anti-inflammatory relief for the first one to two weeks.

  • Abscess drainage

    Ultrasound-guided or surgical drainage if a scrotal abscess develops - specialist urology only.

  • Partner notification

    GUM/BASHH pathway when an STI is confirmed - partners in the previous six months screened and treated to prevent reinfection.

  • Chronic pain pathway

    Pain lasting beyond three months (chronic epididymalgia) - gabapentin, amitriptyline, pelvic floor physiotherapy and selective microsurgical denervation.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, GUM clinician or urologist knows your history and can tell you which parts apply. If in doubt, and especially if pain is sudden and severe, get seen straight away.

  • BASHH. UK national guideline for the management of epididymo-orchitis.

  • European Association of Urology (EAU). Guidelines on urological infections.

  • NICE CKS. Scrotal pain and swelling - diagnosis and management.

  • Public Health England. Mumps orchitis and post-mumps fertility guidance.

Red flags

When scrotal pain needs urgent attention.

Most epididymitis settles quickly with the right antibiotic. These are the situations that need a specialist opinion, imaging or emergency surgery.

  • Testicular torsion

    Sudden severe pain, a high-riding testis and absent cremasteric reflex - a surgical emergency needing immediate urology and Doppler ultrasound.

  • Fournier gangrene

    Rapidly spreading scrotal or perineal necrosis, crepitus and systemic sepsis - a life-threatening emergency requiring urgent surgical debridement.

  • Scrotal abscess

    Fluctuant swelling, worsening pain despite antibiotics or persistent fever - specialist urology for imaging and drainage.

  • Testicular cancer masquerade

    A painless firm testicular mass discovered during workup deserves urgent urology referral - inflammation can mask an underlying tumour.

  • Tuberculous epididymitis

    Indolent, chronic scrotal swelling in an at-risk patient - specialist infectious diseases with dedicated TB testing.

  • Sepsis and systemic infection

    Rigors, hypotension, tachycardia or confusion - admission for IV antibiotics, source control and sepsis management.

  • Recurrent or complicated infection

    Two or more episodes, immunocompromise or structural urinary tract disease - specialist urology assessment and imaging.

  • Fertility concerns after mumps orchitis

    Bilateral testicular involvement or persistent atrophy warrants andrology review and a semen analysis at three to six months.

  • Chronic pelvic pain features

    Pain lasting more than three months - dedicated chronic pain pathway with pelvic floor physiotherapy and neuromodulators.

Living with it

A treatable infection, with a clear recovery.

Four things that make the biggest difference day to day - a firm scrotal support, adherence to antibiotics, prompt partner notification and returning early if anything lingers.

A quiet reminder

Sudden severe pain is never epididymitis until proven otherwise.

If the pain came on abruptly, the testis rides high, or the cremasteric reflex is missing, treat it as torsion and go straight to A&E.

  1. 01 Rest

    Support and elevate

    A firm athletic support and short periods of bed rest reduce swelling and pain for the first few days.

  2. 02 Adherence

    Finish the antibiotic course

    Complete the full 10 to 14 days - stopping early risks abscess, chronic pain and recurrence.

  3. 03 Partners

    Notify and treat partners

    When an STI is confirmed, partners in the previous six months need testing and treatment to prevent reinfection.

  4. 04 Follow-up

    Return if symptoms linger

    Pain, swelling or a lump persisting beyond two weeks needs re-examination, repeat ultrasound and urology review.

Frequently asked

Everything we get asked about epididymitis.

Quick answers on torsion, antibiotic choice, recovery time and fertility.

  • What is epididymitis?

    Epididymitis is inflammation of the epididymis - the coiled tube behind the testis that stores and matures sperm. It often extends to the testis (epididymo-orchitis) and causes unilateral scrotal pain, swelling and tenderness over hours to days.

  • How is it different from testicular torsion?

    Torsion is a surgical emergency with sudden severe pain, a high-riding testis and an absent cremasteric reflex, typically in adolescents and young men. Epididymitis is subacute, more tender over the epididymis and often carries fever or urinary symptoms. Any diagnostic doubt is resolved by urgent scrotal Doppler ultrasound and urology review.

  • What causes epididymitis?

    Under 35, sexually transmitted infections dominate - chlamydia, gonorrhoea and Mycoplasma genitalium. Over 35, urinary pathogens such as E. coli and Klebsiella are more common, often linked to BPH, retention or catheterisation. Mumps and other viruses can cause orchitis, and rarer causes include tuberculosis, brucellosis, autoimmune conditions and post-vasectomy syndrome.

  • Which antibiotic will I be given?

    BASHH advises ceftriaxone 500 mg intramuscular plus doxycycline 100 mg twice daily for 10 to 14 days when an STI is likely. For men over 35 with a suspected urinary source, ciprofloxacin or co-amoxiclav for 10 to 14 days is typical, guided by MSU sensitivities and local antibiotic policy.

  • How long does recovery take?

    Pain and fever usually settle within a week of starting the right antibiotic. Residual swelling and epididymal thickening can take four to six weeks to resolve fully. Persistent pain beyond three months is called chronic epididymalgia and needs a dedicated pain pathway.

  • Will epididymitis affect my fertility?

    Most men recover fully with no impact on fertility. Bilateral involvement, delayed treatment, abscess formation and mumps orchitis carry a higher risk of testicular atrophy or subfertility. Andrology review and semen analysis at three to six months are advised when concerns exist.

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