Epididymitis and orchitis

Question 1

Define epididymitis

Answer 1

inflammation of the epididymis characterised by scrotal pain and swelling (orchitis) of less than 6 weeks duration

Question 2

Define epididymo-orchitis

Answer 2

Syndrome consisting of pain, swelling, and inflammation of the epididymis and/or testis

Question 3

What is the aetiology of epididymitis and orchitis in pre-pubertal children

Answer 3

Idiopathic, self-limiting
Viral infection: adenovirus, enterovirus etc.
Reflux of urine into the ejaculatory ducts - structural urogenital abnormalities

Question 4

What are the causes of epididymitis and orchitis in post-pubertal adolescents

Answer 4

Infection:
- STIs: CHLAMYDIA, gonorrhoea, mycoplasma genitalium, E. coli
- GI: E. coli, enterococcus faecalis
- TB
- Candida (Immunocompromised)
- MUMPS (viral)

Non-infection
Amiodarone use
Behçet’s syndrome and Henoch-Schönlein purpura

Question 5

What are the risk factors for Epididymitis & Orchitis

Answer 5

Unprotected sexual intercourse
Bladder outflow obstruction - BPH, urethral stricture, bladder neck obstruction
Instrumentation of urinary tract - cytoscopic procedures and catheterisation
Immunosuppression
Vasculitis
Amiodarone
Mumps
Exposure to TB

Question 6

What are the symptoms and signs of epididymitis and orchitis

Answer 6

Unilateral scrotal pain and swelling
- Gradual onset, course of a few days
- <6 weeks duration
Tenderness
Hot, erythematous, swollen hemiscrotum
Diffuse enlargement of the testis in epididymo-orchitis
Frequent and painful micturition
Purulent urethral discharge
Pyrexia

Question 7

What investigations should be done for epididymitis and orchitis

Answer 7

Bedside:
- Urine dipstick: +ve leukocyte esterase
- MSU for MC&S: ≥10 WBC per high-power field, culture of causative organism
- Urethral secretion for NAAT
Bloods: HIV serology
Other: surgical exploration (torsion suspected), colour duplex US (enlarged, hyperaemic)

Question 8

What is the management for epididymitis and orchitis in prepubertal children

Answer 8

UTI confirmed: Abx according to UTI treatment regimens

UTI not confirmed: treatment not required
- Reassure that epididymitis is usually a self-limiting conditions
- Ensure bed rest
- Can use paracetamol or ibuprofen for analgesia

Question 9

What is the management for epididymitis and orchitis in adolescents

Answer 9

Manage based on causative organism
STI: refer to GUM clinic, Abx
- Unknown organism: likely chlam/gon → ceftriaxone AND docycline
Enteric: oral ofloxacin for 14 days
Viral: supportive only
amiodarone: dose reduction or discontinue
Vasculitis: refer to rheumatologist

Self-management measures
- Rest
- Scrotal support (supportive underwear)
- Paracetamol and/or ibuprofen for analgesia
- Return if no improvement in 3 days
Resource: British Association for Sexual Health and HIV (BASHH) leaflet

+ follow up after 2 weeks (Reassure that scrotal swelling completely resolves in more than 80% of people by 3 months after antibiotic treatment)

Question 10

What are the complications of epididymitis and orchitis

Answer 10

Sepsis
Abscess formations
Testicular ischaemia/infarction
Epididymal obstruction
Chronic pain following epididymitis
Male factor infertility from testicular atrophy (mumps orchitis)
Reactive hydrocoele

Question 11

What is the prognosis for epididymitis and orchitis

Answer 11

In men with infectious acute epididymitis, symptoms usually resolve rapidly following antibiotic therapy initiation
Could lead to treatment non-adherence and recurrence
Inadequately treated epididymitis, particularly STIs, can lead to epididymal obstruction or testicular atrophy -> infertility problems