Epididymitis + Orchitis

Question 1

What is the age distribution of epididymitis?

Answer 1

Bimodal

15-30 yrs and >60 yrs

Question 2

What is epididymitis and orchitis?

Answer 2

epididymitis - inflammation of the epididymis

Orchitis - inflammation of the testes

epididymitis most cases, followed by epididymo-orchitis and the sole orchitis is rare

Question 3

What is the pathophysiology of epididymo-orchitis?

Answer 3

Local extension of infection from lower urinary tract either via enteric (classic UTI) or non-enertic (sexually transmitted) organisms.

Question 4

What is the most likley cause of epididymo-orchitis in <35 years old?

Answer 4

Sexual transmission - N.gonorrhoeae and C. Trachomatis

Question 5

What is the most likley cause of epididymo-orchitis in >35 years old?

Answer 5

Enteric organism - E.coli, Proteua spp, Klebsiella pneumoniae and Pseudomonas aeruginosa

Question 6

What is mumps orchitis and what is the managemnt?

Answer 6

Orchitis can occur as common complication of mumps viral infection in post-pubertal boys. Typically accompanied by fever, around 4-8 days after the onset of mump parotitis.

Self-limiting and resovles after a week.

If suspected IgM/IgG serolgy should be measured. It is a notifiable disease in the UK.

Question 7

What are the complications of mumps orchitis?

Answer 7

Testicular atrophy

Infertility

Question 8

What are the risk factors for epididymo-orchitis?

Answer 8

Non-enteric causes- MSM, multiple sexual partner, know contact of gonorrhea

Enteric - recent instrumentation or catheterisation, bladder outlet obstruction or immunocompromised

Question 9

What are the clinical features of epididymo-orchitis?

Answer 9

Unilateral scrotal pain (bilateral is rare) and assoiated swelling. Fever and rigors.
Associated symptoms secondary to underying cause e.g. LUTS

Examination: red swollen, tender on plapation and may be assoicated hydrocele

Question 10

What are the specific tests that can be performed on examintion of epididymo-orchitis?

Answer 10

Cremateric relex - intact in cases of epididymitis

Prehns sign - positive

Question 11

What is prehns sign?

Answer 11

Pt is supine and scrotum is elevated by the examiner. Pain is relieved by elevation = positive

Unreliable so not used very often

Question 12

What are the differential diagnosis for epididymo-orchitis?

Answer 12

Testicular torsion - most important as emergency

Other:
Testicular trauma 
Testicular abscess 
Epidiymal cyst 
Hydrocele 
Testicular tumour

Question 13

What investigations could be requested in epididymo-orchitis?

Answer 13

Urine dipstick and culture

First-void urine - sent for nucleic acid amplification test (NAAT) in non-enteric cases
STI screening
Routine bloods +/- blood cultures (systemic signs of infection)

Imaging - usually clinical diagnosis but can do ultrasound imaging via US doppler - rule out complications and other diagnosis.

Question 14

What is th initial management of epididymo-orchitis?

Answer 14

Outpatient managementin most cases

Appropriate antibiotics and analgesia. Bed rest and scrotal support

Abstain from sexual activity and appropriate contraceptive advise.

Chronic epididymo-orchitis with persistent pain may warrant orchiectomy.

Question 15

What is the first line antibiotics for enteric organisms in epididymo-orchitis?

Answer 15

Ofloxacin 200mg PO BD for 14 days
Or
Levofloxacin 500mg BD for 10 days

Question 16

What is the first line antibiotics for non-enteric organisms in epididymo-orchiti

Answer 16

Ceftriaxone 500mg IM single dose and Doxycycline 100mg PO twice daily for 10-14days (with Azithromycin 1g PO single dose added if gonorrhoea likley)

Question 17

What are the complications of epididymo-orchitis?

Answer 17

Symptoms improve within 48 hrs of starting antibiotics.

Reactive hydrocele
Abscess (rare)
Testicular infarction (rare)