Epididymitis and orchitis

Question 1

Define

Answer 1

o Acute epididymitis is inflammation of the epididymis characterised by scrotal pain and swelling of less than 6 weeks’ duration. Usually unilateral.

Question 2

What are the causes?

Answer 2

•	Most cases are INFECTIVE in origin
•	Bacterial (most common)
o	If < 35 yrs and sexually active: Chlamydia trachomatis or Neisseria gonorrhoeae
o	If > 35 yrs: mainly enteric pathogens (e.g. Enterobacter, Klebsiella, E.coli), anal sex, may be associated with bladder outlet obstruction, recent instrumentation of the urinary tract, or systemic illness
o	RARE: TB, syphilis 
•	Viral
o	Mumps 
•	Fungal
o	Candida if immunocompromised 
•	1/3 are IDIOPATHIC

Question 3

What are the risk factors?

Answer 3

o	Diabetes 
o	Unprotected sex 
o	Bladder outflow obstruction 
o	Cystoscopy or urinary catheter 
o	Rare: vasculitis (e.g. Henoch-Schonlein purpura), amiodarone,TB, immunosuppression

Question 4

Epidemiology

Answer 4

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

Question 5

What are the presenting symptoms?

Answer 5

• Unilateral painful, swollen and tender testis or epididymis
• Symptoms <6 weeks
• NOTE: less acute onset than testicular torsion
• Penile discharge
• IMPORTANT: ask about sexual history

Question 6

What are the signs?

Answer 6

• Swollen and tender epididymis or testis
• Scrotum may be erythematous and oedematous
• Pyrexia
• Walking will be painful
• Eliciting a cremasteric reflex may be painful

Question 7

What are the 1st investigations?

Answer 7

• Gram stain of urethral secretions
o >5WBC per oil immersion field, presence of intracellular gram negative diplococci
• Urine
o Dipstick – positive leucocyte esterase
o Early morning urine collections for microscopy (>10 WBC per high-power field) and culture
• Nucleic acid amplification test (NAAT)/ culture of urethral secretions or first void urine for chlamydia or gonorrhoea

Question 8

What are some investigations to consider?

Answer 8

•	Bloods
o	FBC - high WCC
o	High CRP 
o	U&Es
•	Imaging
o	Increased blood flow on duplex examination 
o	Color duplex ultrasound

Question 9

How would you manage?

Answer 9

• Medical
o Antibiotics (if STD, ceftriaxone + doxycycline. If non-STD, quinolone)
o Pain relief
• Surgical
o Exploration of testicles if testicular torsion cannot be excluded clinically
o Required if an abscess develops

Question 10

What are the possible complications?

Answer 10

• Chronic pain
• Testicular ischaemia/ infarction
• Epididymal obstruction
• Male factor infertility
• Abscess
• Fournier’s gangrene (if the infection is left untreated and spreads)
• Mumps orchitis could cause testicular atrophy and fertility issues

Question 11

What’s the prognosis?

Answer 11

• GOOD if treated

* May take up to 2 months for the swelling to resolve