Epididymo-Orchitis Flashcards
What is Epididymo-Orchitis?
Acute infection of the epididymus (epididymitis) +/- testes (orchitis)
What are the peak ages of incidence?
Bimodal distribution
Males aged 15-30 yrs & > 60yrs
What is the pathophysiology of EO?
Local extension of infection from the lower urinary tract (bladder & urethra), either via enteric (e.g. UTI) or non-enteric (e.g. STI) organisms
What is the most common cause in younger men?
STIs
such as N. gonorrhoeae & C. trachomatis
(E.coli in patient’s who have anal sex)
What is the most common cause in the > 60s ?
Enteric organism from a UTI
Most common pathogens are E. coli, Proteus spp., Klebsiella pneumoniae, and Pseudomonas aeruginosa
How else can EO arise?
Viral infection (e.g. mumps)
Drug induced
How does Mumps orchitis present & what is the disease progression?
Unilateral / bilateral orchitis +/- fever, around 4-8 days after the onset of mumps parotitis.
Self-resolves within a week w/ supportive management, but can lead to complications such as testicular atrophy and infertility.
How do you investigate suspected mumps orchitis?
Mumps IgM/IgG serology should be measured
Mumps is a notifiable disease in the UK, meaning that the local Health Protection Team must be informed if there is suspicion of mumps.
What are the risk factors for EO?
For non-enteric causes:
- Unprotected sex
- Males who have sex with males (MSM)
- Multiple sexual partners
- Known contact of gonorrhea
For enteric causes:
- Recent instrumentation / catheterisation
- Bladder outlet obstruction (e.g. prostate enlargement, urethral stricture)
- Immunocompromised state
What are the symptoms of EO?
- Unilateral scrotal pain & swelling
- Gradual onset
- Fever / rigors
- Associated symptoms
- Dysuria
- Storage LUTS
- Urethral discharge possible
- Relevant sexual history
What are the signs of EO on examination?
- Unilateal redness & swelling of affected side
- Rarely bilateral
- Tenderness of epididymis +/- the testis
- Associates hydrocele possible
- Normal cremasterix reflex
- +ve Prehn’s sign
- Pain relieved by elevating testis.
What is a positive Prehn’s sign? & How reliable is it in clinical practice?
Testicular pain is relieved by elevation (while pt is supine)
- Suggestive of epididymitis
Prehn’s sign is unreliable
- It has good sensitivity, but relatively poor specificity, therefore is not used routinely.
What is the most important differential to consider when a patient presents with testicular pain? & why?
Testicular torsion
Because it is a surgical emergency
How is the presentation of testicular torsion different from EO?
- Age
- Torsion occurs mostly in patients under 25 (esp teenagers)
- Pain
- Torsion pain is more severe & has rapid onset
- Exam
- High-lying, laterally orientated testis suggests torsion
- Absent cremasteric reflex
- -ve Prehn’s sign
Aside from testicular torsion, what other differential diagnoses may you consider with a presentation of EO?
- Testicular trauma
- Testicular tumour
- Testicular abscess
- Epididymal cyst
- Hydrocele
How do you investigate EO?
- Urine dipstick & urine culture (MC&S)
- For evidence of infection
- First void urine should be collected and sent for Nucleic Acid Amplification test to assess for N. gonorrhoea, C. Trachomatis
- STI testing
- Routine bloods
* FBC & CRP = Looking for infective causes
+/- Blood cultures (if there’s evidence of systemic infection
- Doppler USS
* To confirm diagnosis and rule out abscess
How do you manage Orchitis?
1. Supportive measures
- Bed rest
- Scrotal support
- Sufficient analgesia
2. Antibiotics (definitive treatment that can be started empirically prior to culture results)
Enteric organisms:
- Ofloxacin 200mg PO BD for 14 days
OR
- Levofloxacin 500mg BD for 10 days
STI organisms:
- Ceftriaxone 500mg IM single dose
AND
- Doxycycline 100mg PO twice daily for 10-14 days
+/- Oral Azithromycin 1g single dose (if gonorrhoea likely)
IV Abx if septic / unwell
3. Abstinence from sexual activity until antibiotics finished & counselling on safe sex
4. Safety netting = “Seek further assessment if symptoms do not resolve or get worse”
What are complications of EO?
- Reactive hydrocele formation
- Abscess formation (rare)
- Testicular infarction (rare)
- Chronic pain
- Infertility
