Epididymo-orchitis
Overview
Epididymo-orchitis is inflammation of the epididymis, and occasionally the testis.
Possible causes
- The most common cause in men <35 years is Chlamydia trachomatis and occasionally Neisseria gonorrhoeae.
- In sexually active men of ANY age, Chlamydia trachomatis and Neisseria gonorrhoeae remain the most likely cause of epididymo-orchitis. But in men who practise insertive anal sex, and men who have had recent instrumentation, enteric pathogens (for example, Escherichia coli and Proteus spp) become increasingly likely.
- In males of all ages paramyxovirus (mumps) and amiodarone use should be considered.
- Rarer causes include tuberculosis, brucellosis, Candida spp, cryptococcosis, and Behçet’s syndrome.
Clinical presentation
| Symptoms | Comments/Considerations |
|---|---|
| Scrotal pain and swelling | Usually unilateral. Swelling, induration and tenderness of the epididymis is the most common sign. Consider cancer if swelling is confined to the body of the testis. If very acute onset or severe pain consider torsion and urgent surgical referral. |
| Dysuria or urethral discharge | Urethral symptoms are often absent despite the presence of STIs (if present the patient would have sought treatment earlier). |
| Suprapubic pain, frequency, and nocturia | Suggests urinary pathogen rather than STI. |
Diagnosis
| Infection | Site/Specimen | Test |
|---|---|---|
| Chlamydia | FPU | NAAT |
| Gonorrhoea | FPU | NAAT. If NAAT test result positive, take swab at relevant site(s) for culture, before treatment. |
| Urinary pathogens | MSU | Microscopy, culture, and sensitivities |
| FPU – First pass urine NAAT – Nucleic Acid Amplification Test MSU – Mid-stream urine |
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Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Investigations:
- Physical examination to determine exact site and nature of swelling and tenderness
- If present, collect sample of urethral discharge for MC&S
- Collect FPU and MSU specimens
- If diagnosis uncertain, Doppler ultrasonography may help exclude testicular infarction, torsion, or tumour.
Special considerations
If diagnosis remains uncertain and pain is severe, refer for urgent urological review. Torsion can result in the loss of the testis within hours.
Management
Treat sexually active men with epididymo-orchitis presumptively for gonorrhoea and chlamydial infection.
| Principle treatment options | |
|---|---|
| Infection | Recommended |
| Chlamydia/gonorrhoea suspected | Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat PLUS Azithromycin 1g PO, stat PLUS EITHER Doxycycline 100mg PO, starting the next day, BD for 14 days OR Azithromycin 1g PO, stat 1 week later |
Treatment advice
- For men who engage in insertive anal sex, treat empirically as above, however if response is poor, alternative treatment may be required to treat enteric organisms. Seek specialist advice.
- Modify therapy based on the results of investigations and clinical response. In severe cases, treatment may need to be continued for up to 3 weeks. Seek specialist advice.
- Bed rest, scrotal support and analgesia are commonly required. Complete resolution of the swelling may take several weeks, but a substantial response should occur in 4-5 days.
Other immediate management
- Advise no sexual contact for 7 days after treatment is completed
- Advise no sex with partners from the last 6 months until the partners have been tested and treated if necessary
- Comprehensive STI testing may be appropriate, depending on the patient's sexual history
- Contact tracing
- Provide patient with factsheet.
Contact Tracing
- If STI-related, all sexual partners from the past 6 months should be tested and treated
- If urinary tract infection, contact tracing is not required.
See Australasian Contact Tracing Manual - Epididymitis for more information.
Follow up
Follow up at 4-5 days provides an opportunity to:
- Assess treatment response and reassess in light of the test results, including antibiotic sensitivities
- If STI-related, confirm that sexual partners have been properly managed. Offer more contact tracing support if needed
- Provide further sexual health education and prevention counselling
- Men with chlamydia should be retested for reinfection after 3 months
- Men with gonorrhoea should be retested 3 months after exposure
- Confirmed urinary tract infections in men often require further investigation or urological referral.
Consider testing for other STIs, if not undertaken at first presentation, or retesting post the window period.
For test of cure (TOC) and retesting advice see:
Auditable outcomes
If STI-related, 100% of regular partners are tested and treated.
References
RCGP Sex, Drugs, HIV and Viral Hepatitis Group British Association for Sexual Health and HIV (BASHH) 2013.