Orchitis/epididymitis

Causes of epididymitis

Sexually active men <35 years of age  Chlamydia trachomatis Neisseria gonorrhoea

Men >35 years of age  Coliform bacteria (Escherichia coli)

Children  Enteroviruses Adenoviruses Mumps E. coli

Chronic infection  Mycobacterium tuberculosis Many of the above untreated

Immunocompromised  Cytomegalovirus (CMV) Cryptococcus Pseudomonas aeruginosa Klebsiella pneumoniae

Rare  Ureaplasma urealyticum Corynebacterium spp. Mima polymorpha Proteus mirabilis Brucella Treponema pallidum Filariasis

Non infectious  Sarcoidosis Behcet’s disease Amiodarone Idiopathic Polyarteritis nodosa

• The likely pathogenesis is due to infection by any of several pathogens 
• When the infection lasts for more than 3 months it can be considered as chronic epididymitis.
• There are several other causes of epididymitis that can only be diagnosed once infection has been ruled out. These include autoimmune disease, vasculitis and idiopathic causes

Clinical features

• insidious onset
• isolated scrotal pain 
• severe cases
  • scrotal swelling and pain
  • fever, rigors
  • lower urinary tract symptoms – increased frequency, dysuria and urgency. 
• predisposing factors
  • sexual activity
  • heavy physical exertion
  • prolonged periods of sitting (including bicycle/motorbike riding).
• examination
  • indurated, tender or swollen epididymis 
  • can be associated with orchitis
  • consequent hydrocoele and erythema
  • epididymitis
    • pain isolated to the upper pole of the testicle, 
    • positive Prehn’s sign – pain relief with lifting the affected testicle
  • cremasteric reflex intact
    • However, there is a significant proportion of cases of testicular torsion or torsion of the appendix testis that can also present with these signs

Investigations

• urine specimen for analysis
• urethral swab 
• ultrasonography

treatment

• analgesia
• NSAIDs
• Ice
• scrotal support (comfortable underwear that elevates the scrotum)

Empirical antibiotics:

• Ceftriaxone 500 mg in 2 mL of 1% lidocaine intramuscularly, or 500 mg intravenously, as a single dose 

PLUS

• Doxycycline 100 mg orally, 12-hourly for 14 days OR  Azithromycin 1 g orally, as a single dose, repeated 1 week later.

Not sexually active Epididymo-orchitis

• likely to be caused by an organism from the urinary tract.
• For adults: treat  for 14 days.
• For prepubertal boys
  • perform urinalysis
  • more than 80% of cases in these patients are not bacterial and do not require antibiotic therapy
  • If urinalysis is negative for leucocyte esterase and nitrite, treat the child symptomatically 
  • If the urinalysis is positive for leucocyte esterase or nitrite, take a midstream urine sample for culture and treat as for a urinary tract infection for 14 days

• recurrent epididymitis should warrant investigations into possible structural abnormalities
  • renal ultrasonography
  • uroflowmetry
  • cystoscopy
  • micturition cysto-urethrography