Epididymo-orchitis is a clinical syndrome consisting of pain, swelling and inflammation of the epididymies and testes. It occurs most commonly as a complication of a urethral infection caused by sexually transmitted pathogens (Chlamydia trachomatis, Neisseria gonorrhoea) in sexually active men, or a urinary tract infection caused by enteric Gram-negative bacteria (Pseudomonas, Klebsiella or Proteus spp, E. Coli) in non-sexually active men (eg prepubertal boys, older men). It can also occur secondary to a number of systemic bacterial infections (tuberculosis, syphilis) and viral infections (mumps). Men who engage in insertive anal sex are at risk of infection with sexually acquired enteric pathogens in addition to other sexually transmitted pathogens.
Differential diagnosis includes:
- Testicular torsion
- Torsion of epididymal appendage
- Epididymal cyst
- Testicular tumour
Testicular torsion is a surgical emergency which should be considered in all patients and excluded first. It most commonly occurs in males aged <20 but can occur at any age. If testicular torsion is suspected, the patient should be referred for URGENT surgical assessment (ultrasound scan with Doppler are helpful but should not delay surgical assessment)
Diagnosis of epididymo-orchitis
- The epididymis is painful, swollen, and tender. Often the epididymis is indurated and distinctly more affected than the testis, but in advanced cases or viral orchitis the testis is involved.
- The presence of urethritis, urinary tract infection or fever and onset over more than a few hours, help to distinguish this from torsion of the testis, but urethritis is frequently absent in sexually-acquired epididymitis.
- Gonorrhoea is suggested by a purulent urethral discharge or by epididymo-orchitis in a gay or bisexual man.
Urethral swab for urgent Gram stain if discharge is present.
First void urine tests for chlamydia, gonorrhoea and Mycoplasma genitalium (as per NSU treatment guideline)
MSU for microscopy, culture and sensitivities
If clinically suspected consider tests for mumps, tuberculosis and brucellosis.
Pain relief, rest and scrotal support
Antibiotics should aim to cover the most likely causes.
Where an STI is the most likely cause:
azithromycin 1g stat plus
- doxycycline 100 mg twice daily for 14 days (some men may require an additional week of treatment.)
In addition, if gonorrhoea is suspected or possible then ADD: Ceftriaxone 500 mg stat IMI
If an enteric organism is suspected:
Ciprofloxacin 500mg twice daily for 10 days (Ceftriaxone 500 mg IMI may be added for men who are at risk of both enteric and sexually transmitted pathogens, e.g. men who report insertive anal intercourse)
Review at 48 hours and if there is no improvement the diagnosis should be re-evaluated or admission considered.
If symptoms of sepsis or systemic symptoms are present admission to hospital for rest and intravenous antibiotic treatment should be considered.
All partners of men with epididymo-orchitis not secondary to an enteric pathogen should be tested and managed accordingly.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.
Last Updated April 2018