Epididymitis and Orchitis

Question 1

Define epididymitis and orchitis

Answer 1

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

Question 2

Aetiology of epididymitis and orchitis

Answer 2

Infectious:

• Sexually active men of all ages: Chlamydia trachomatis, Neisseria gonorrhoea, Mycoplasma genitalium, E. coli
• E. coli and Enterococcus faecalis commonly cause epididymo-orchitis in men >35 years or men that have anal sex.
• Older men (>35): E. coli, proteus sp.
• Endemic areas: Tuberculous
• Immunocompromised: Candida sp
• Viral: mumps

Non-infectious (Reversible sterile epididymitis):
Therapy with amiodarone (antiarrhythmic)
Vasculitic processes in Behçet’s syndrome and Henoch-Schönlein purpura

Question 3

Risk factors for epididymitis and orchitis

Answer 3

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 4

Epidemiology of epididymitis and orchitis

Answer 4

Most common cause of acute scrotal pain is epididymitis
Majority aged 10-39 years
Majority of cases in children occur around the time of puberty in early adolescence

Question 5

Symptoms of epididymitis and orchitis

Answer 5

Unilateral scrotal pain (Gradual onset | course of a few days | <6 weeks duration)
Scrotal 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 6

Signs of epididymitis and orchitis on examination

Answer 6

Unilateral scrotal pain 
Scrotal swelling
Tenderness
Hot, erythematous, swollen hemiscrotum
Diffuse enlargement of the testis in epididymo-orchitis
Enlarged or tender prostate

Question 7

Investigations for epididymitis and orchitis

Answer 7

Urine dipstick: positive leukocyte esterase test
Gram stain and culture of urethral secretions: positive for causative organism
Urine microscopy: raised WBC (>10)
Urine culture: isolate causative organism
NAAT or urethral secretions

HIV or syphillis test: may be +ve

Colour duplex Ultrasonography: Epididymis is enlarged and hyperaemic, with a low-resistance monophasic arterial waveform pattern

Surgical exploration: oedematous epididymitis with vascular congestion and evidence of surrounding inflammatory reaction (exclude testicular torsion)

Question 8

Management for epididymitis and orchitis (bacterial, amiodarone-induced, viral)

Answer 8

Bacterial

1. Antibiotics
   - Gonorrhoea/chlamydia: Ceftriazone IM and doxycycline PO
   - Enteric: oflofloxacin PO
   - M genitalium: moxifloxacin PO
2. Supportive: paracetamol, bed rest, scrotal elevation, IV fluid if systemically ill

Amiodarone induced: reduce dose or discontinue amiodarone
Viral/idiopathic: supportive

Question 9

Complications of epididymitis and orchitis

Answer 9

Abscess formations 
Testicular ischaemia/infarction 
Epididymal obstruction 
Chronic pain following epididymitis
Male factor infertility

Question 10

Prognosis for epididymitis and orchitis

Answer 10

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