Epididymitis & orchitis (URO) Flashcards
What is epididymitis?
Inflammation of the epididymis characterised by scrotal pain and swelling of <6 weeks duration
What is the epididymis?
Cord that connects the testis with the ductus deferens
What are the main causes of epididymitis? (2 + 3)
- UTI (older men and children) - E. coli (and other enteric pathogens)
- STI (young males <35y):
- Chlamydia trachomatis most common
- Neisseria gonorrhoeae is second most common
- Mycoplasma genitalium
What is orchitis?
Inflammation of the testis
What are the features of testicular torsion (differential for epididymitis)? (4)
- age <20
- severe pain
- more acute onset
- negative Prehn’s sign
What are some risk factors for epididymitis & orchitis? (8)
- unprotected sexual intercourse (and MSM - anal intercourse)
- bladder outflow obstruction (incomplete emptying = higher voiding pressures = reflux of infected urine into ductal system and spread of pathogens to epididymis)
- instrumentation of urinary tract (cystoscopic procedures and urethral catheterisation)
- immunosuppression
- vasculitis
- amiodarone
- mumps
- exposure to TB
What age group is most commonly affected by epididymitis?
20-30 years (most sexually active)
What are the features of mumps (risk factor for epididymitis/orchitis)? (4 + 2)
- fever
- malaise
- muscular pain
- parotitis (earache or pain on eating)
- prevented via MMR vaccine, notifiable disease
- complications: orchitis and pancreatitis
What are the clinical features of epididymitis? (5)
- unilateral scrotal pain and swelling - gradual onset over several days, radiates to ipsilateral flank, <6 weeks, walking painful
- tenderness (along posterior testis)
- hot, erythematous, swollen hemiscrotum
- frequent and painful micturition (LUTS)
- purulent urethral discharge (STI) - found on primary catch urine sample
VS testicular torsion - sudden, severe pain in <20, negative Prehn
What is there a history of in epididymitis/orchitis? (2)
- Sx of lower UTI - dysuria, frequency, urgency
- Sx of STI - penile discharge
What are the clinical features of orchitis? (3)
- sudden onset of nausea and vomiting
- sudden fever
- swollen and tender testicle/s - primarily unilateral
What might you see on examination in epididymitis/orchitis? (6)
- positive Prehn sign - pain relief on elevation of scrotum/testes (testicular torsion will be -ve)
- pyrexia
- enlarged/tender prostate on DRE (bladder outflow obstruction)
- epididymo-orchitis: hot, enlarged, swollen, erythematous testis on one side
- cremasteric reflex may be painful (cremasteric muscle contraction –> ipsilateral elevation of testicle)
- inguinal lymphadenopathy
Cremasteric reflex ABSENT in testicular torsion
What are the first-line investigations for epididymitis? (4)
- Gram stain and culture of urethral secretions
- urine dipstick
- urine MC&S
- nucleic acid amplification test (NAAT) of urethral secretions/first-void urine for C. trachomatis, N. gonorrhoeae and M. genitalium
Why do we do urinalysis in epididymitis/orchitis?
To identify pyuria or bacteruria
What investigation is done to identify the causative agent for epididymitis in sexually active younger adults?
Nucleic acid amplification test (NAAT) of urethral secretions / first-void urine for C. trachomatis, N. gonorrhoeae and M. genitalium
What investigation is done to identify the causative agent for epididymitis in older adults with low-risk sexual history?
Urine culture (MSU for MC&S)
What investigation is done in epididymitis/orchitis to rule out the most important differential diagnosis?
Duplex ultrasound of scrotum - rule out testicular torsion
Decreased flow = testicular torsion
Increased flow = epididymitis
What are some differential diagnoses for epididymitis? (5)
-
testicular torsion:
- sudden-onset, severe, unilateral scrotal pain
- absence of Sx suggesting infection e.g. LUTS
- negative Prehn’s sign (and Cremasteric reflex)
- Ix: colour duplex USS
- acute idiopathic scrotal oedema - paediatric, redness and oedema (painless)
- infected hydrocoele
- strangulated inguinal hernia
- testicular tumour
What supportive measures do we give in epididymitis/orchitis? (4)
- NSAIDs
- application of cold pack
- bed rest
- scrotal elevation (+ve Prehn’s sign)
How would we go about treating the infection in epididymitis/orchitis?
Start empirical Abx based on the most likely causative organism, and adjust Abx therapy once causative organism identified
What empirical Abx are given for epididymitis?
Ceftriaxone 500mg IM + oral doxycycline 100mg BD 10-14 days
What Abx are given to treat epididymitis where gonorrhoea/chlamydia suspected?
Ceftriaxone + doxycycline
(+ azithromycin IF gonorrhoea is likely)
What Abx are given to treat epididymitis where enteric organisms suspected (e.g. E. coli)?
Levofloxacin
What Abx are given to treat epididymitis where Mycoplasma genitalium suspected?
Moxifloxacin
What Abx are given to treat epididymitis if >35 years?
Mostly non-STI, associated UTI common = ciprofloxacin or ofloxacin
Avoid ciprofloxacin in patients with epilepsy
Who else do we need to treat in epididymitis/orchitis?
Treat sexual partners
What are some complications of epididymitis? (8)
- epididymo-orchitis - spread of infection from epididymis to testicle
- abscess formation (Abx, surgical drainage)
- testicular ischaemia/infarction (occlusion/compression of BS –> testicular atrophy –> infertility - mumps orchitis)
- epididymal obstruction (–> infertility)
- chronic pain
- male factor infertility
- reactive hydrocoele
- Fournier gangrene - acute necrotic infection of scrotum, penis or perineum
What is the most common complication of mumps?
Orchitis
What are some complications of orchitis? (2)
- atrophy
- hypofertility
Describe the prognosis of epididymitis.
Symptoms usually resolve rapidly following initiation of appropriate Abx therapy
