Epididymitis and orchitis

Question 1

What is epididymitis/ orchitis?

Answer 1

Inflammation of the epididymis (epididymitis) or testes (orchitis)
o 60% of epididymitis is associated with orchitis
o Most cases of orchitis are associated with epididymitis

Question 2

What causes epididymitis and orchitis?

Answer 2

Most cases are INFECTIVE in origin (spread from urethra or bladder), most common cause = E. Coli 
1. Bacterial
o If < 35 yrs: Chlamydia and Gonococcus
o If > 35 yrs: mainly coliforms (e.g. Enterobacter, Klebsiella)
o RARE: TB, syphilis
2. Viral
o Mumps
3. Fungal
o Candida if immunocompromised
4. Drugs: Amiodarone (non-infective cause) -  which resolves on stopping the drug
1/3 are IDIOPATHIC

Question 3

What are the risk factors for Epididymitis and Orchitis?

Answer 3

• Diabetes
• Unprotected sexual intercourse
• Bladder outflow obstruction
• Immunosuppression
  o Rare: vasculitis (e.g. Henoch-Schonlein purpura)

Question 4

Summarise the epidemiology of epididmytis and orchitis

Answer 4

● COMMON
● Affects all age groups
● Most commonly: 20-30 yrs

Question 5

What are the presenting symptoms of epididymitis and orchitis?

Answer 5

● Painful, swollen and tender testis or epididymis
● NOTE: sudden onset but less acute onset than testicular torsion
● Penile discharge – found on primary catch urine sample
● Dysuria
● Sweats/fever
● IMPORTANT: ask about sexual history

Question 6

What signs of epididymitis and orchitis can be found on physical examination?

Answer 6

● Swollen and tender epididymis or testis
- Unilateral scrotal pain and swelling, develops over several days and radiates to the ipsilateral flank
● Scrotum may be erythematous and oedematous
● Pyrexia
● Walking will be painful
● Eliciting a cremasteric reflex may be painful
- Tenderness along posterior testis
- Positive Prehn Sign → pain relief on elevation of the testes (-ve in Testicular Torsion)
- Hot, erythematous, swollen hemiscrotum
- Low grade fever
- Hx of..
*Symptoms of lower UTI → dysuria, frequency, urgency
*Symptoms of STI → penile discharge

Question 7

What investigations are used to diagnose/ monitor epididymitis and orchitis?

Answer 7

1. Urinalysis → identify pyuria(wbc in urine) or bacteriuria
2. Urine Culture (MSU for MC&S) → identify causative organism
3. FBC → high WCC
4. Bloods
   o FBC - high WCC
   o High CRP
   o U&Es
5. Duplex Ultrasound of Scrotum → rule out testicular torsion

Question 8

How is epididymitis and orchitis managed?

Answer 8

1. Symptomatic Management → bed rest, scrotal elevation, NSAIDs, application of cold pack
2. Antibiotic Treatment → Start empiric antibiotic treatment based on the most likely causative organism. Adjust antibiotic therapy once the causative organism is identified.
   - Most commonly doxycycline (<35, covers chlamydia), ceftriaxone (if gonnorrhoea suspected) or ciprofloxacin (>35)
3. Surgical
   o Exploration of testicles if testicular torsion cannot be excluded clinically
   o Required if an abscess develops – abscess drainage

Question 9

What are some complications that may arise from epididymitis and orchitis?

Answer 9

● Pain
● Abscess
● Fournier’s gangrene (if the infection is left untreated and spreads)
● Mumps orchitis could cause testicular atrophy and fertility issues

Question 10

Summarise the prognosis for patients with epididymitis and orchitis

Answer 10

● GOOD if treated
● May take up to 2 months for the swelling to resolve