Epididymitis and orchitis

Question 1

What is epididymitis/orchitis?

Answer 1

Pain, swelling and inflammation of epididymis or testis or both

Question 2

List 3 causes of epididymo-orchitis.

Answer 2

Causes:

• STIs (<35yrs) - chlamydia trachomatis, neisseria gonorrhoea.
• UTIs (>35yrs) - ascending E-coli, Pseudomonas spp. (gram -ve enteric organisms)
• Post-operative - catheterisation/instrumentation
• Mumps

Rare:

• Extrapulmonary TB (rare)
• In immunocompromised hosts - e.g. brucellosis, coccidioidomycosis, blastomycosis, cytomegalovirus, candidiasis
• Behcet’s disease
• Adverse effect of amiodarone

Question 3

List 3 causes of acute orchitis.

Answer 3

• Viral - mumps (common), coxsackievirus A, varicella and echoviral infections (rare)
• Bacterial and pyogenic infections - E. coli, Klebsiella, Pseudomonas, Staphylococcus, Streptococcus
• Granulomatous - syphilis, TB, leprosy, ,Actinomyces spp. and fungal diseases(rare)
• Trauma
• Idiopathic

Question 4

How common is epididymo-orchitis?

Answer 4

• The most common cause of acute scrotal pain is epididymitis
• Acute epididymitis - most common in 15-30yr olds and <60yrs
• Mumps orchitis occurs in 40% of postpubertal boys with mumps
• Pre-pubertal cases are rare
• Outbreak was seen due to reduced uptake of MMR vaccine in 2004 onwards but cases have now reduced.

Question 5

What is the pathogenesis of epididymo-orchitis?

Answer 5

Secondary to retrograde ascent of urinary pathogens from the urethra and bladder, via the ejaculatory ducts and vas deferent to the epididymis.

Inflammation starts in the tail of the epididymis and spreads to the head and body of epididymis. In many cases the testes also become involved causing epididymo-orchitis . Mechanisms of non-bacterial epididymitis is unknown.

Question 6

What are the risk factors for epididymo-orchitis?

Answer 6

• Unprotected sexual intercourse
• Bladder outflow obstruction
• Instrumentation of urinary tract - cystoscopy, catheterisation

Other:

• Immunosuppression
• Vasculitis
• Amiodarone
• Mumps
• Exposure to TB

Question 7

What are the signs/symptoms of epididymo-orchitis?

Answer 7

• Unilateral
• Scrotal pain and swelling of gradual onset - over few days (unlike testicular torsion)
• <6 weeks - longer means chronic inflammation
• Tenderness of epididymis - felt as a tubular structure which lies posterior to testis and runs in saggital plane
• Hot, erythematous

Uncommon:

• Frequent and painful micturition - common in lower UTI
• Purulent urethral discharge - ?STI
• Pyrexia - ?infectious cause if systemic symptoms
• fluctuant swelling or induration of scrotal tissue - ?reactive hydrocele or abscess formation
• Enlarged or tender prostate- ?BPH can cause BOO and increase acute epididymitis risk

Question 8

What investigations would you do for epididymo-orchitis?

Answer 8

Depends on age of patient e.g. younger screen for STI, older MSU for MCS.

• Urethral swab - gram stain for urethritis if symptoms present
• Urine dipstick - positive for leukocytes in UTI
• Urine MC&S - check for chlamydia and gonorrhoea; send early morning urine sample for NAAT (nucleic acid amp testing) for TB
• STI screen - including syphilis and HIV

Other:

• Colour duplex ultrasonography -?abscess formation or testicular tortion
• Surgical exploration - if testicular tortion cannot be confidently excluded

Question 9

What is the management of epididymo-orchitis?

Answer 9

BASH guidelines; if organisms unknown:

• Ceftraixone and doxycycline - covers gonorrhoea/chlamydia 500mg IM once or 10-14days 100mg BD respectively.
• Analgesia - e.g. paracetamol/ibuprofen/naproxen

Conservative:

• Bed rest, scrotal elevation

Question 10

What are the complications?

Answer 10

• Abscess formation - 3-8%
• Testicular ischaemia/infarction - due to occlusion of the testicular blood vessels
• Epididymal obstruction
• Chronic pain following epididymitis - epididymectomy considered only in extreme cases.
• Male factor infertility

Question 11

What is the prognosis with epididymo-orchitis?

Answer 11

Usually resolves with initiation of antibiotic therapy.

Question 12

Which of these is true about epididymo-orchitis?

1. The patient presents with sudden onset of pain
2. The most common cause in children is mumps
3. In children, there is often an underlying congenital abnormality
4. In sexually active young men (<35years), the most common causative organism is Chlamydia
5. A first-catch urine specimen is more likely to show an abnormality than an MSU

Answer 12

3, 4, 5

The most common causative organism is E. Coli. In young men <35years, the most common causative organism is Chlamydia, followed by N. gonorrhoea.