Epididymo-orchitis

Question 1

A 56 year old man presents with a painful, swollen right testis. He has recently experienced several urinary tract infections. How would you manage him?

Answer 1

Impression
With the painful swollen R testis (unilateral) on a background of recurrent UTI, I am most concerned about epididymo-orchitis as the PDx for this patient. In sexually active males, this is most likely caused by STIs including chlamydia, gonorrhoea, and mycoplasma genitalium. There are several important differentials I would like to consider and rule out in this patient;

• infective: Fourniers gangrene, Abscess, mumps
• torsion: testicular, appendices
• neoplasia: testicular cancer (usually painless and younger demographic)
• inguinal hernia
  Other causes of swollen testes:
• hydrocoel
• varicocoel

Goals

• conduct thorough Hx/Ex/Ix, utilising scrotal US to rule out differentials and exclude important complications such as abscess and fourniers
• treat definitively, likely with empirical ABx if provisional is correct.

Question 2

Epididymo-orchitis - History

Answer 2

History

• Sx: pain (SOCRATES) - sudden vs gradual onset, location (migration down abdo wall, etc). further characterise UTI sx, infective sx (fevers, tachy, palps, etc)
• HPI/risks: history of hernias, abdo wall surgery, Genito hx like undescended testes, hypospadias, etc. immunocompromised, anal penetrative sex,
• MMR vaccination (mumps), family history
• PMHx (prostatitis, BPH, renal disease), PSHx, meds, allergies, SNAP

Question 3

Epididymo-orchitis - Examination

Answer 3

Examinaiton
- general observation + vitals

External male gentalia:

• inspection: swelling, blue dot sign, high-riding, lateral testis (torsion)
• palpation: swelling, can get above lump? (hernia), tenderness
• Prehn’s sign; pain relieved with elevation of testis (positive in epididymo-orchitits)
• Cremasteric reflex: positive in al Ddx’s except testicular torsion (stroke medial thigh, causes contraction of the ipsilateral cremasteric muscle)
• transillumination test (hydrocoele)

Question 4

Epididymo-orchitis - Investigations

Answer 4

Investigations

• Bedside: UA and urine MCS for UTI, STI screen
• bloods: FBC, UEC, LFT, CRP/ESR, pre-ops (G+H)
• Imaging: Testicular US, rule out abscess, torsion, hernia, malignancy

Question 5

Epididymo-orchitis - Management

Answer 5

Management
Depends on the underlying cause. If concerned about a torsion, then arrange for emergent theatres with Uro review for surgical detorsion and orchidopexy to prevent future events.

Supportive:

• scrotal support
• analgesia as appropriate (According to WHO ladder)

If PDx is correct and epididymo-orchitis;
- Treat based on STI vs UTI associated infections;
UTI - trimethoprim if non-severe, or cephalexin. If severe the IV gent +amp

STI - ceftriaxone + doxycycline + metronidazole
- contact tracing

If Fournier’s - then surgical debridement and IV ABx