Epididymitis and Orchitis

Definition

Epididymitis and orchitis are inflammatory conditions of the male reproductive system. Epididymitis refers to inflammation of the epididymis, the coiled tube at the back of the testicle that stores and carries sperm. Orchitis refers to inflammation of the testicle. These conditions can occur separately or together (epididymo-orchitis).

Aetiology

Epididymitis and orchitis can result from various causes, including:

Bacterial infections: Most commonly caused by sexually transmitted infections (STIs) such as chlamydia and gonorrhoea. Non-sexually transmitted bacteria like E. coli can also cause these conditions.
Viral infections: Mumps virus can cause orchitis, particularly in post-pubertal males.
Urinary tract infections (UTIs): Can spread to the epididymis and testicles.
Trauma or surgery: Injury or procedures involving the scrotum or groin can lead to inflammation.

Pathophysiology

The inflammation in epididymitis and orchitis typically starts with an infection in the urinary tract or sexually transmitted infection that ascends through the urethra, vas deferens, and eventually reaches the epididymis or testicle. This leads to localised inflammation, swelling, and pain. In viral cases, such as mumps orchitis, the virus directly infects the testicular tissue.

Risk Factors

Unprotected sexual intercourse.
History of STIs.
Recent urinary tract surgery or instrumentation.
Prolonged use of a urinary catheter.
Structural abnormalities of the urinary tract.
Immunosuppression or chronic illnesses such as diabetes.

Signs and Symptoms

Scrotal pain and swelling, often unilateral.
Painful urination or urethral discharge (if associated with STI).
Fever and chills.
Erythema and warmth of the scrotum.
Tenderness in the affected testicle or epididymis.
Sometimes, systemic symptoms like malaise and myalgia.

Investigations

Clinical history and physical examination, including a detailed sexual history.
Urinalysis and urine culture: To detect infection and identify causative organisms.
Sexually transmitted infection (STI) testing: Swabs or urine tests for chlamydia and gonorrhoea.
Scrotal ultrasound: To assess for abscess formation, testicular torsion, and other differential diagnoses.
Blood tests: Full blood count (FBC), C-reactive protein (CRP), and other markers of infection.

Management

Primary Care Management

If the patient is unwell, refer urgently to hospital and then stabilise the patient, ensuring airway, breathing, and circulation (ABCs).
Empirical antibiotic therapy: Based on likely pathogens. For STI-related cases, referral to a sexual health clinic for appropriate management is recommended.
Analgesia and anti-inflammatory medications: To manage pain and reduce inflammation.
Scrotal support and elevation: To reduce discomfort.
Patient education: Safe sex practices and the importance of completing the antibiotic course.
Referral to a specialist (urologist) if symptoms persist and the patient has been assessed in the hospital and told to go to the GP (if they have not already been referred by hospital doctors).

Specialist Management

Further diagnostic evaluation if there is no response to initial treatment.
Intravenous antibiotics: For severe cases or if the patient is systemically unwell.
Surgical intervention: In cases of abscess formation or when conservative management fails.
Management of complications: Such as chronic pain, abscesses, or infertility.

Example Management for Epididymitis and Orchitis

A patient presenting with scrotal pain and swelling, along with fever and urethral discharge, should be evaluated for epididymitis and orchitis. In primary care, empirical antibiotic therapy may include ofloxacin 200 mg twice daily or levofloxacin 500 mg once daily for 10-14 days for non-STI related cases. Pain can be managed with NSAIDs, and the patient should be advised on scrotal support and safe sex practices. If the infection is suspected to be STI-related, the patient should be referred to a sexual health clinic for appropriate management. If symptoms persist, the patient may be referred to a urologist for further evaluation and potential surgical intervention. Regular follow-up is essential to monitor response to treatment and manage any complications.

References

NICE. (2024). Epididymitis and Orchitis: Diagnosis and Management. Retrieved from NICE
NHS. (2023). Epididymitis and Orchitis. Retrieved from NHS
Centers for Disease Control and Prevention (CDC). (2022). Sexually Transmitted Infections Treatment Guidelines. Retrieved from CDC
Stephens, M. (2016). Epididymitis and Orchitis: Clinical Features and Management. BMJ.
McConaghy, J. R., & Panchal, B. (2016). Epididymitis: An Overview. American Family Physician.