Epididymo-orchitis

epididymitis |

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

Specimen collection

Clinician collected | Self-collection

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 EITHER Doxycycline 100mg PO, starting the next day, BD for 14 days OR Azithromycin 1g PO, stat and repeated 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.

Last Updated: Wednesday, 11 July 2018