Epididymo-orchitis (EO) Flashcards
Epididymo-orchitis - describe the clinical syndrome?
pain, swelling and inflammation of the epididymis +/- testes
Cause for EO can be categorised into 5 broad categories - what are they?
Bacterial Viral Granulomatous Other infective causes Non-infective
What are the typical organisms implicated in bacterial EO?
Sexually transmitted
- chlamydia trachomatis
- neisseria gonorrhoea
Gram negative enteric organisms
What is used to differentiate between STI vs enteric organism risk for EO?
Age
BUT
important to take complete sexual history
What age is most commonly associated with STI EO?
<35
What other group are more at risk of enteric organism EO?
Men who have insertive anal sex
What increases the risk of enteric organism EO in all?
Recent instrumentation of GU tract
- prostate biopsy
- vasectomy
- catheterisation
What proportion of men with anorectal malformations will develop EO?
20%
Is ureaplasma urealyticum a cause of EO?
Evidence lacking
Often found in association with chlamydia or gonorhoea
Is mycoplasma genitalium a cause of EO?
Evidence lacking
however biologically possible
There has been a case of PVL-staph aureus EO, how did the patient present?
Scrotal pain
Folliculitis with superficial abscess
Healthy individual
What is the most likely cause of viral induced EO?
Mumps
What proportion of post-pubertal males will develop EO from mumps?
40%
What is the main granulomatous disease to consider in EO?
TB
How common is TB EO?
Rare presentation
What people might get TB EO?
high prevalence countries
previous TB history
Immunodeficient
BCG instillation of bladder (increasingly reported)
Brucella, candida and schistosomiasis are all rare causes of EO, when should brucellosis be considered?
Patient from endemic area
- Mediterranean
- North & East Africa
- Middle East
- South & Central ASIA
- Central & South America
What other symptoms may precede Brucella EO?
Fever, lethargy, night sweats
What non-infective causes have been implicated in EO?
Behcet's disease Amiodarone Henoch-Schonlein Purpura (children) Familial Mediterranean fever Polyarteritis nodosa
What percentage of men with Behcet’s disease will develop EO?
12-19%
How does epididymo-orchitis typically present?
Acute onset
Unilateral scrotal pain
swelling
erythema
What associated symptoms MAY occur with EO?
urethritis urethral discharge fever dysuria frequency urgency
What is the MOST important differential to EO?
testicular torsion
Who is most at risk of testicular torsion?
Neonate
Around puberty
BUT can occur any age
What are the typical symptoms of testicular torsion?
Sudden onset pain (within hours) Severe (typically) Radiates to GROIN or lower ABDOMEN Nausea or vomiting (associated) SIMILAR pain in past (intermittent torsion)
On clinical exam what may suggest testicular torsion?
Testis more tender than epididymis
Swollen
high riding
horizontal torted testis
What is typically absent in torsion vs EO?
urethritis or evidence of UTI on preliminary tests
When can EO be treated and torsion disregarded as a differential?
When a diagnosis of EO can be clearly made
What specific features may suggest TB EO?
Subacute/chronic Painless or painful scrotal swelling (epididymus first) systemic symptoms of TB Scrotal sinus Thickened scrotal skin
What specific features may suggest Mumps EO?
Preceding:
- headache
- fever
Then:
unilateral or bilateral parotid swelling
7-10 days:
unilateral testicular swelling
epididymitis
What are the findings of EO on clinical examination?
Palpable UNILATERAL FIRM swelling and tenderness of the epididymus starting from TAIL at LOWER POLE of testis spreading to whole epididymis and testis
What complications may occur as a result of EO?
Reactive HYDROCELE
ABSCESS formation
INFARCTION of testicle
INFERTILITY
Describe the relationship between EO and infertility?
Poorly understood
Mumps orchitis leads to testicular atrophy
What percentage of mumps orchitis will result in reduced fertility?
13%
with Bilateral orchitis
Who are more likely to experience complication of EO?
Patients with UROpathogen-related EO, NOT STI
What investigations are useful in work up of EO?
Microscopy for urethritis and GNDC FVU dipstick FVU NAAT Urethral swab culture MSSU Colour duplex US - for complications
Which investigation is indicated to exclude testicular torsion?
Surgical exploration ONLY
US will miss up to 3% cases in expert hands
Who should have referral to urologist in EO?
Possible testicular torsion
Urinary tract pathogen confirmed EO
What investigations should be considered for EO?
THREE early morning urines for AAFB IV urography Renal tract US (TB EO typically associated with renal tract pathology) Biopsy CXR
What percentage of patients with brucellosis develop EO?
20%
How do you confirm Brucella EO?
Brucella serology IgM & IgG
EO likely due to STI? Treatment?
Ceftriaxone 1g IM AND doxycycline 100mg twice daily 10-14 days
EO likely due to chlamydia or non-gonococcal STI? Treatment?
Doxycycline 100mg BD 10-14 days
EO likely due to enteric pathogen? Treatment?
Ofloxacin 200mg oral twice daily FOURTEEN days
EO likely due to chlamydia AND gonorrhoea AND enteric organism? Treatment?
Ceftriaxone 1g IM and OFLOXACIN 200mg BD 10 days
When should treatment for mycoplasma genitalium be given for EO?
If mycoplasma genitalium has been tested and identified
What is the treatment for mycoplasma genitalium EO?
Moxifloxacin 400mg once daily FOURTEEN days
What has been shown to have NO benefit in treatment of EO?
Corticosteroid
When will swelling in EO resolve following treatment?
3 months, 80% of cases
If little improvement in swelling or pain following treatment for EO what differentials should be considered?
Testicular ischaemia/infarction
Testicular/epididymal tumour
Progression to abscess
Alternative infective causes - TB or mumps
