Epididymo-orchitis

• Acute epididymo-orchitis is a common cause of testicular pain and swelling.
• It is caused by acute inflammation of the epididymis (epididymitis) that may affect the testicle (orchitis).
• Most commonly the aetiology is infectious through the spread of pathogens from the urethra or bladder via the vas deferens. It may be related to urinary tract infections or sexually transmitted infections.
• Testicular torsion must be considered in anybody presenting with acute testicular pain, particularly in children, adolescents and younger men. 
• Epididymo-orchitis is most commonly caused by sexually transmitted infections or urinary pathogens.
• Sexually transmitted organisms tend to be considered in patients younger than 35, who have had previous STIs or are engaging in high-risk sexual activities
• Urinary tract infection-related organisms tend to be considered in patients older than 35, particularly in the presence of risk factors like recent catheterisation or recurrent UTIs.
• Sexually transmitted infection

  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Mycoplasma genitalium
  • Gram-negative enteric organisms (in those engaging in penetrative anal sex)
• Non-sexually transmitted infection

  • Gram-negative enteric organisms (e.g. Escherichia coli)
  • Candida
  • Mumps
  • TB
  • Brucellosis
• Non-infectious

  • Behcet’s disease
  • Amiodarone induced
• Patients will complain of testicular pain, signs of systemic infection may be present.
• Symptoms

  • Testicular pain
  • Nausea and vomiting
  • Fever
  • Dysuria
• Signs

  • Testicular swelling
  • Palpable, swollen, tender epididymis
  • Testicular erythema
  • Tender testicle
  • Hydrocele (reactive)
  • Urethral discharge
• Consider signs and symptoms of potential underlying systemic illnesses that may cause epididymo-orchitis such as mumps and tuberculosis.
• Bedside

  • Vital signs
  • Urine dipstick (send MSU)
  • Sexual health screen (or refer to local GUM clinic)
• Bloods

  • FBC
  • UEs
  • CRP
  • Syphilis
  • Bloodborne virus screen
  • Mumps serology (if clinically indicated)
  • Blood cultures (if pyrexial)
• Imaging

  USS may confirm the diagnosis, showing inflammation of the epididymis. Reactive hydroceles may be present.

  USS is also useful to exclude testicular tumours, another cause of testicular pain.
• Antibiotics are used to treat suspected bacterial causes of epididymitis.
• Advise the person to abstain from sexual contact until they and any partner(s) have completed treatment and follow up if there is a confirmed or suspected sexually transmitted infection (STI)
• If an enteric organism is the most likely cause:

  • urine dip stick and MSU
  • Consider treating empirically with oral ofloxacin or levofloxacin
• If most likely due to any STI:

  • Urgent referral to STI clinic for testing, treatment and contact tracing
  • Treat empirically with single dose IM ceftriaxone
  • Plus oral doxycycline for 10-14 days
• Mumps is a rarer cause of orchitis
• General management:

  • Supportive care - analgesia (paracetamol and NSAIDs), scrotal support (supportive underwear), if symptoms no better or worsening after 3 days need urgent medical review
  • Review patient after 2 weeks - if symptoms persistent consider ultrasound scrotum and/or urology referral
• Prehn's sign is used to discriminate between bacterial epididymitis and testicular torsion

  • Positive Prehn's sign is when there is pain relief with lifting the affected testicle - suggests epididymitis not torsion
• The cremasteric reflex will be in tact in cases of epididymitis but may be absent in cases of torsion

  • Elicited by stroking the inner aspect of the thigh
  • Causes the cremasteric muscle within the scrotum to contract and pull the testicle up