Epididymo-orchitis

Question 1

Describe epididymo-orchitis in language for a patient

Answer 1

Epididymo-orchitis is a condition which causes swelling and pain inside the scrotum. This can either affect the epididymis the storage unit for sperm just above the testes or the testes which is called orchitis in greek. It is most commonly caused by an infection. Either a sexually transmitted infection or a urine infection

Question 2

What is the most common cause of EO in men aged < 35 years

Answer 2

Sexually transmitted causes

e.g. CT or GC most commonly or in MSMs it could be a sexually transmitted enteric organism

Question 3

What is the most common cause for EO in men aged >35 years

can you name two risk factors

Answer 3

Most commonly non-sexually transmitted gram negative enteric organism causing urinary tract infections

two risk factors include - recent catheterisation, recent prostate biopsy, or vasectomy

Question 4

In MSM what organisms can cause EO

Answer 4

enteric sexually transmitted organisms

Question 5

Name three non-infective causes of EO

Answer 5

drug causes - amiodarone, following BCG treatment for bladder cancer
vasculitis e.g. HSP in a child, polyarteritis nodosa
familial mediteranean fever
beckets disease

Question 6

List the infective causes of EO

Answer 6

bacterial causes - STIs most commonly chlamydia and gonorrhoea; urine pathogens, enteric organisms, TB (rare)
viral - mumps, adenovirus, enterovirus

rarer causes include brucella, fungi and schistosomiasis

Question 7

what are the clinical symptoms a man might present with suggestive of EO

Answer 7

acute onset unilateral pain, redness and swelling of the scrotum
dependent upon the cause - if a UTI - fevers, urinary frequency, dysuria, urgency
if STI - urethral discharge, urethritis

Question 8

what is an important differential diagnosis that needs to be excluded in a man who presents with acute onset testicular pain and swelling?

Answer 8

Testicular torsion

Question 9

Describe the findings you might find in a male presenting with testicular torsion

Answer 9

acute onset unilateral severe pain
the pain is usually worse in the testes than in the epididymis on examination
the testes can be pulled higher on the affected side and horizontally lying
can be associated with nausea and vomitting

Question 10

What methods of imaging could you consider in a male whom presents with acute onset pain and swelling of the testes and you want to rule out testicular torsion?

Answer 10

consider CDU (colour duplex ultrasound) however need to be aware that this has high false negative rates and is subjective so if unsure consider the need for urgent surgical exploration

Question 11

in suspected testicular torsion what is the time limit from onset of symptoms to try and preserve the testes?

Answer 11

6 hours before testicular ischaemia occurs

Question 12

List the complications that can result from EO

Answer 12

1. Reactive hydrocele
2. Abscess formation
3. Infertility - the relationship between fertility and EO is poorly understood - in mumps orchitis 30-50% of patients will develop testicular atrophy; 13% of these will have reduced fertility

Question 13

What are the first line investigations you should do in a male presenting with acute onset testicular pain and you suspect EO

Answer 13

1. MSU for urine dip + MSU
2. FVU for CT/GC
3. urethral smear for microscopy
4. GC culture plate
5. HIV and STS bloods

if worried about testicular torsion –> consider CDU (colour doppler USS)

Question 14

in a 25 year old male, with recent CFP and reports 2 other causal female partners in the last 2 months with signs and symptoms suggestive of EO how would you treat?

Answer 14

Likely STI pathogen - ceftriaxone 1g IM stat, doxycycline 100mg BD 14 days

Question 15

in a 25 year old male, with recent CFP and reports 2 other causal female partners in the last 2 months with signs and symptoms suggestive of EO how would you treat? Urethral smear negative for GC i.e. likely Chlamydia or non-gonococal causative STI causative organism

Answer 15

consider

a) doxycycline 100mg BD for 14 days or
b) ofloxacin 200mg BD for 14 days

Question 16

In a MSM whom presents with rectal discharge and symptoms of EO how would you consider treating? (i.e likely an STI and enteric organism)

Answer 16

Ceftriaxone 1 gram IM and ofloxacin 200mg BD for 14 days

Question 17

a 45 year old male presents to clinic with signs and symptoms consistent of EO, his urethral smear is negative and urine dip shows 2+ leu and nitrites. He is heterosexual and has a RFP of 20 years. How would you treat the EO?

Answer 17

most likely due to an enteric organism; low risk for UTI

a) ofloxacin 200mg BD for 14 days or
b) levofloxacin 500mg OD for 10 days

Question 18

how soon following treatment should patients symptoms of EO start to improve

Answer 18

after 3 days. but the swelling can persist for up to 3 months

Question 19

when should you offer TC f/u when you have treated someone for EO

Answer 19

Telephone follow up at 72 hours and then face to face review at 2 weeks

Question 20

if a patients MSU comes back positive for E.Coli and they have been treated where should you refer them?

Answer 20

positive MSU in a male needs investigation - referral to urology –> for renal tract USS, renal tract CT and cystoscopy