Epididymo-orchitis


Epididymo-orchitis is a clinical syndrome consisting of pain , swelling and 
inflammation of the epididymis with or without inflammation of the testis

Epididymitis and Orchitis -respective definitions

 Acute epididymitis → inflammation of the epididymis characterized by scrotal pain and swelling of < 6 wks and Orchitis → acute inflammatory reaction of the testis secondary to infection

Main differential is torsion of the spermatic cord
 Epididymitis is the most common cause of scrotal pain in adults Patients with testicular torsion present usually earlier than those with epididymitis Epididymitis can be acute and chronic ( > 3 months ) Isolated orchitis is rare ( commonest cause is mumps )

STI eg unprotected or anal intercourse H/O Mumps or contact with TB Instrumentation and indwelling catheters structural or functional abnormality of the urinary tract Systemic illness and immunosuppression

Causes -Chlamydia trachomatis N gonorrhoeae M genitalum Gram negative enteric organisms Gram negative enteric organisms eg E Coli
eg obstructive urinary disease , urinary tract surgery or instrumentation Mumps can cause epididymo-orchitis at any age Amiodarone – symptoms improve when Rx stopped ( high drug conc in usually in head of epididymis ) Vasculitis- rare cases reported with Bechet’s and Henosch Schonlein purpura Idiopathic Polyarteritis nodosa

Onset – sudden or gradual Pain Swelling H/O trauma UTI Recent viral infection
Testicular swelling happens 7-10 days after parotid swelling and fever ( scrotal involvement can happen without systemic symptoms ) Sexual history Unilateral scrotal pain and swelling of gradual onset 
B/L in 5-10 % cases
Sudden onset suggests torsion Urethritis symptoms
○ urethral discharge
○ dysuria
○ penile irritation May accompany systemic features as fever chills No nausea or vomiting ( unlike torsion ) UTI related symptoms Tenderness of the affected side particularly epididymis Palpable swelling of epididymis
usually starts in the tail of the epididymis and spreading to involve the whole of the epidisymis and testis Erythema & milld scrotal cellulitis Generalised testicular swelling Positive Phrens sign and intact cremasteric reflex Reactive hydrocele Painless and nontender ifTB

Clinical diagnosis based on 
history
examination
preliminary investigations Urethral swab FPU / urethral swab for NAAT Disptcik and MSU Culture of urethral secretions Colour duplex US Test for TB – morning urines for alcohol and acid fast bacilli Testicular torsion is the main DD . torsion more likely if
○ pt under 20 yrs ( but can occur at any age )
○ pain is sudden ( within hours )
○ pain is severe
○ initial testing does not show urethritis or likely UTI Acute idiopathic scrotal oedema Infected hydrocele Strangulated inguinal hernia Testicular tumour ( usually painless swelling gradual onset )

Use oral cefixime 400 mg as an alternative to IM ceftriaxone if needed Or use 
○ Ofloxacin 200 mg bd for 14 days
○ Levofloxacin 500 mg od for 10 days
 If Gonorrhoeae suspected add Azithromycin to Ceftriaxone and Doxycyline Arrange contact tracing ( GUM clinic or in Primary care ) To avoid sexual contact during treatment and until partner – traced and treated Ofloxacin 200 mg bd for 14 days or
Levofloxacin 500 mg bd for 10 days


 If quinilone contraindicated 
Augmentin for 10 days
avoid if hepatic impairment or h/o previous hepatic dysfunction following augmentin use Swelling worsened or no improvement in 3 days of antibiotic treatment –> reassess and change antibiotics ( based on lab result ) or consider admission F/U in 2 weeks to check compliance , partner notification and improvement Swelling persists after abx rx is completed → refer urology to exclude testicular cancer Confirmed UTI – refer for further investigations for structural abnormality or Ur tr obstruction STI – refer for full screening including blood borne viruses

References
 The 2016 European guideline on the management of epididymo-orchitis international Union against Sexually Transmitted Infections ( IUSTI ) January 2017 The role of clinical examination in the differential diagnosis of acute testicular pain Best BETS 2006 Medscape Epididymitis Christina B Ching et al January 2018 Practice >> 10-minute consultation Epididymo-orchitis BMJ 2011 ;342 ;d1543 BMJ Best Practice Acute epididymitis Scrotal swelling – NICE CKS April 2017 Acute epididymo-orchitis Emma J street et al Medicine , 2014-06-01 , Volume 42 , Issue 6, Pages 338-340 Epididymo-orchitis Patient UK November 2016

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