Bilateral funiculitis presenting with acute bilateral testicular pain and fever: A case report

Naveen PM 1*, Gowdham Pannirselvam2

1Nursing Officer- ER, Kauvery Hospital, Marathahalli, Bengaluru

2Sr. Nurse Educator, Kauvery Hospital, Marathahalli, Bengaluru.

*Correspondence

Abstract

Background

Funiculitis is an inflammatory condition involving the spermatic cord and may present with scrotal or testicular pain. Because acute scrotal pain has several important differential diagnoses, appropriate clinical assessment and imaging are essential.

Case Presentation

A male patient presented to the emergency department with complaints of pain involving both testicular regions associated with fever. The patient had a history of recent physical/sexual contact. His temperature was recorded as 102°F. Investigations included complete blood count, renal function tests, urine routine examination, sexually transmitted disease (STD) screening and ultrasonography of the scrotum. Ultrasonography demonstrated anechoic/echogenic inflammatory changes around the spermatic cord at the root of both testes with increased vascularity, raising suspicion of bilateral funiculitis. Injectable antibiotic therapy was initiated according to the treating team’s clinical assessment. However, the patient subsequently Left Against Medical Advice (LAMA) with the prescribed antimicrobial treatment, and further clinical follow-up was unavailable.

Conclusion

This case highlights the importance of considering spermatic cord inflammation in patients presenting with acute scrotal pain and fever. Early clinical evaluation, appropriate imaging, laboratory investigations and consideration of infectious and sexually transmitted etiologies are important. The patient’s LAMA status emphasizes the importance of counselling regarding treatment adherence and follow-up.

Keywords: Funiculitis; Spermatic cord; Bilateral testicular pain; Scrotal pain; Fever; Ultrasonography; Sexually transmitted infection; LAMA.

Introduction

Funiculitis refers to inflammation involving the spermatic cord. The spermatic cord contains important structures including the vas deferens, testicular vessels, lymphatic vessels, nerves and associated connective tissue. Inflammatory conditions of the male genital tract can produce scrotal and testicular pain and may overlap clinically with other causes of acute scrotal pain. Epididymitis and epididymo-orchitis are important differentials, while testicular torsion must always be considered in appropriate acute presentations because it is a surgical emergency.

In sexually active males, sexually transmitted infections such as Chlamydia trachomatis and Neisseria gonorrhoeae are recognized causes of acute epididymal inflammation. Therefore, sexual history and appropriate STI evaluation are important components of assessment. This case describes a patient presenting with bilateral testicular pain and fever, with ultrasonographic findings suggestive of bilateral funiculitis, who subsequently left the hospital against medical advice.

Anatomy and Physiology

Spermatic Cord

The spermatic cord extends from the abdominal/inguinal region through the inguinal canal to the testis. It contains:

  • Vas deferens
  • Testicular artery
  • Arteries supplying the vas deferens and cremasteric structures
  • Pampiniform venous plexus
  • Lymphatic vessels
  • Autonomic and sensory nerves
  • Connective tissue and fascial coverings

Image Source: American Family Physician; Evaluation of Scrotal Masses; 2008;78(10)

The spermatic cord therefore provides important vascular, neural, lymphatic and reproductive connections between the testis and the proximal structures. Detailed anatomical studies demonstrate complex vascular, lymphatic and neural components within the cord.

Normal Function

The testis performs two major functions:

  1. Spermatogenesis-production of spermatozoa.
  2. Endocrine function – production of testosterone by Leydig cells.

The vas deferens transports sperm from the epididymis toward the ejaculatory pathway.

The pampiniform plexus contributes to thermoregulation of the testis, while the vascular supply maintains adequate oxygen and nutrient delivery.

Pathophysiology

Infectious/inflammatory stimulus
↓
Inflammatory response around spermatic cord
↓
Vasodilatation and increased vascularity
↓
Tissue edema and inflammatory changes
↓
Irritation of local sensory nerve structures
↓
Scrotal/testicular pain and tenderness
↓
Possible fever/systemic inflammatory response

In this patient, the ultrasound finding of increased vascularity and inflammatory changes around the spermatic cord was considered supportive of an inflammatory process consistent with funiculitis.

Case Presentation

A male patient presented to the emergency department with a chief complaint of pain in both testicular regions. The patient also had a history of fever, with a documented temperature of 102°F. During history taking, recent physical/sexual contact was reported. This history was considered clinically relevant because sexually transmitted infections can contribute to inflammatory conditions of the male genital tract. However, the presence of recent sexual contact alone does not establish an STI as the cause of this patient’s condition.

Presenting complaints

  • Bilateral testicular/scrotal pain
  • Fever – 102°F
  • Recent physical/sexual contact

Investigations

The following investigations were performed:

InvestigationPurpose
USG ScrotumEvaluation of testicular, epididymal and spermatic cord structures
Urine Routine ExaminationEvaluation for urinary/genitourinary infection
CBCAssessment for systemic/inflammatory response
Renal Function Tests (RFT)Assessment of renal function before/while planning treatment
STD PanelEvaluation for sexually transmitted infections

Ultrasonography Findings

  • USG of the scrotum
  • Anechoic/echogenic inflammatory changes around the spermatic cord at the root of both testes with increased vascularity, raising suspicion of funiculitis.
  • The bilateral involvement was an important feature of this case.

Provisional Diagnosis

Based on the clinical presentation and ultrasound findings, the patient was provisionally diagnosed with:

Bilateral Funiculitis

The clinical differential diagnosis in a patient with acute scrotal pain may include:

  • Epididymitis
  • Epididymo-orchitis
  • Orchitis
  • Testicular torsion
  • Torsion of testicular appendage
  • Inguinal pathology
  • Other infectious/inflammatory causes

Treatment

Considering the patient’s fever and suspected inflammatory/infectious process, injectable antibiotic therapy was initiated as prescribed by the treating physician.

Outcome

The patient was counselled regarding the need for continued treatment, monitoring and follow-up. However, the patient left the hospital against medical advice (LAMA/AMA) with the prescribed antibiotics.

Discussion

Funiculitis involves inflammation of the spermatic cord and can present with scrotal or testicular discomfort. The spermatic cord contains vascular, lymphatic, neural and reproductive structures, and inflammatory changes in this region can produce significant pain.

In the present case, the patient had bilateral testicular pain with fever, and ultrasonography demonstrated inflammatory changes around the spermatic cords with increased vascularity. These findings led to suspicion of bilateral funiculitis.

The history of recent sexual contact was clinically relevant because sexually transmitted pathogens can cause inflammatory syndromes involving the male genital tract. CDC guidance notes that C. trachomatis and N. gonorrhoeae are important causes of acute epididymitis in sexually active men. However, the present case should not attribute causation to an STI unless the patient’s STD results confirm it.

The bilateral nature of the symptoms is also noteworthy. CDC guidance indicates that bilateral symptoms can broaden the differential diagnosis of testicular pain and require careful clinical assessment.

Another important aspect of this case was the patient’s LAMA status. Leaving before completion of treatment and follow-up creates uncertainty regarding clinical progression, treatment response and possible complications. For suspected sexually transmitted infections, follow-up and appropriate partner evaluation may be important when indicated by laboratory and clinical findings.

Conclusion

Bilateral funiculitis is an uncommon inflammatory condition that can present with significant bilateral testicular pain and fever. In this case, ultrasonography demonstrated inflammatory changes around the spermatic cords with increased vascularity, supporting the clinical suspicion of funiculitis. Recent sexual contact warranted STI evaluation, although exposure history alone cannot establish an STI-related etiology. The patient received prescribed antimicrobial therapy but subsequently left against medical advice, preventing assessment of treatment response and final outcome.

References

  1. Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
  2. Centers for Disease Control and Prevention. Epididymitis: STI Treatment Guidelines [Internet]. Atlanta: CDC; 2021 [cited 2026 Oct 4]. CDC Epididymitis Treatment Guidelines
  3. Wang XK, Wang HZ, Fu DJ, Lai MK. Microanatomy of the spermatic cords during microsurgical inguinal varicocelectomy: initial experience in Asian men. Asian J Androl. 2012;14(6):897-9.
  4. Möller R. Arrangement and fine structure of lymphatic vessels in the human spermatic cord. Andrologia. 1980;12(6):564-76.
  5. Add the patient’s actual laboratory values, exact ultrasound report wording, antibiotic name/dose, and STD results before journal submission.

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