Dear Dr. G,

I am a fit and healthy man in my early forties.

I have just started a new sexual relationship, and that is going well, until I started noticing slight discomfort in my left scrotum a fortnight ago.

I don’t usually get so hung up about my balls, but the swelling has doubled in size over the last few days, and the pain is also worrying me a great deal.

I also don’t know whether I am just paranoid, but I have noticed that the painful urination has somewhat persisted, and I am struggling to empty my bladder.

Besides, I have also noticed a mild fever that has been recurring. I may have caught an infection somewhere, but I am really puzzled about how an infection could have got into my testicles.

I cannot help but wonder whether I have contracted some sort of sexually transmitted infection (STI).

I am too embarrassed to tell anyone about my lopsided, painful ball.

Therefore, I have decided to put Dr. G on the spot about my painful testicles.

Can you tell me what could possibly be wrong with my testicles?

Is it normal for the swelling of the testicles to progress so fast?

Can this be a sexually transmitted infection?

What are the possible causes of swelling in the scrotum?

The swelling of the testicle tends to increase in size and become more uncomfortable. Is it a bad sign?

I am worried and embarrassed about someone “fondling” my balls. Should I go and see the doctor? Regards

Sad Swollen Steven

Epididymal orchitis is an infection of the testicle and the surrounding structures responsible for testosterone production and spermatogenesis. Such infections can occur in men throughout their lives. Children and adolescent males are susceptible to the infection due to smegma from the foreskin. Sexually active younger men typically develop the infection after sexual intercourse, resulting in painful swelling of one testicle. Sexually induced infections are often associated with painful, frequent urination and urethral discharge. Common sexually transmitted infections, such as gonorrhea and chlamydia, trace back from the urethra into the testicles following unprotected sexual intercourse. Although sexually transmitted causes of epididymal orchitis are common, non-sexually induced infections of the testicles are also well recognised.

Infections of the testicles in older men are usually caused by enteric bacteria such as E. coli. Such infections arise from dehydration or bladder outflow obstruction due to prostate enlargement. Benign Prostatic Hyperplasia is common in older men, causing incomplete bladder emptying after urination. The residual urine tends to become infected in the bladder, and the backwards infection of the testicle occurs when cystitis is not treated early enough. Prostate-related infections of the testicles can recur frequently unless the issues of bladder outflow obstruction are treated accordingly. Besides bacterial infections, mumps is a viral illness caused by a paramyxovirus that is well-known to be associated with painful infections of the testicles. Although such viral infections are well recognised in pediatric populations, mumps orchitis is also rising in numbers due to unvaccinated individuals.

Symptoms of epididymal orchitis are typically sufficient for making a diagnosis. These include rapid, painful swelling of the testicle, accompanied by redness of the scrotum. Palpation of the testicle reveals a significant disparity in size, and the scrotal pain is relieved by the elevation of the affected testis. Rapid and painful testicular swelling is likely caused by an infection known as epididymal orchitis. On the other hand, gradual swelling of the testicles tends to be benign in nature. Benign swellings of the testicles, including varicoceles, hydrocele, epididymal cysts and hernia, develop slowly, and most of these swellings are painless. Even cancer of the testicles can mimic the symptoms of epididymal orchitis. Careful scrotal examinations and painless ultrasound imaging are definitive in determining the diagnosis.

Both acute and chronic forms of epididymal orchitis can be effectively treated with antibiotics. The preferred treatment for sexually transmitted bacteria is Ceftriaxone and Azithromycin. Enteric bacterial infections in older men are typically sensitive to antibiotics such as Ciprofloxacin and Augmentin. Complete resolution of the infection is possible with an adequate duration of antibiotics. Complications such as chronic epididymal orchitis and abscesses can also be detected through ultrasound scans. Delayed treatment of the infection may be associated with infertility or scrotal abscess, which could necessitate surgical removal of the testicle.

There is no doubt that the presence of scrotal swelling can be both embarrassing and worrying. The importance of simple examinations by doctors and ultrasound scans in determining the diagnosis and initiating treatment for epididymal orchitis is often reiterated. On the contrary, delayed diagnosis and late treatment often result in severe complications related to testicular malfunctions. Men who are embarrassed yet terrified about swellings of the testicles often turn to Dr. G for advice. His view is: “There comes a point in every man’s life with scrotal swellings to say enough is enough, and getting himself fondled in the sacs can potentially save his ball and even his life!”