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Key points
- Epididymo-orchitis: acute inflammation of epididymis and testis, usually due to ascending infection; peak incidence in men aged 20–40.
- Aetiology: N. gonorrhoeae, C. trachomatis (young patients); E. coli (older men/children); non-infective causes rare (e.g. sarcoidosis, vasculitis).
- Risk factors: UTIs, diabetes (esp. SGLT-2 inhibitors), incomplete bladder emptying, catheters, immunosuppression, STIs, MSM, multiple partners.
- Symptoms: acute unilateral scrotal pain/swelling/erythema, LUTS, dysuria, urethral discharge, fever, systemic illness.
- Examination: tender firm testis, irregular epididymis, reactive hydrocele, erythematous oedematous scrotal skin, ± abscess, systemic signs (fever, tachycardia).
- Differentials: testicular torsion (esp. young), hydatid torsion, trauma, tumour, hydrocele, mumps orchitis.
- Investigations: urinalysis (leucocytes/nitrites), MSSU, FBC (↑WCC), CRP, U&Es, STI screen, Doppler ultrasound if diagnosis unclear/complications suspected.
- Management: analgesia, scrotal support; antibiotics per likely cause, STI: ceftriaxone + doxycycline; enteric: ofloxacin or co-amoxiclav; drainage of abscess, orchidectomy if infarction or unresponsive infection; refer unwell cases to urology
- Complications: Fournier’s gangrene, sepsis, abscess, testicular infarction, chronic pain, infertility.
Introduction
Epididymo-orchitis is a common infective condition causing inflammation within the epididymis (epididymitis) and the testes (orchitis). It is characterised by swelling, pain and erythema of the affected epididymis/testicle and may involve adjacent structures and/or the overlying skin.
It is a common condition, affecting 25 to 65 per 10,000 people per year, with a peak incidence among men aged 20-40 years old.1-2 As such, it is an important differential diagnosis for acute scrotal pain. It can be acute, chronic or recurrent.
Aetiology
The testis is part of the male reproductive system. The testicles function to produce spermatozoa and testosterone from Leydig cells under the influence of the hypothalamic-pituitary-gonadal axis.3
Epididymo-orchitis is typically an acute process, and inflammation is most commonly associated with ascending infection from the urethra or bladder.
Infective
In the young, sexually active population, the infective organisms are usually N. gonorrhoeae, C. trachomatis or coliforms.
The most common organisms in older men and the paediatric population are those causing urinary tract infections (UTI), such as E. coli.4 Rarely, orchitis can be caused by extrapulmonary tuberculosis.
Non-infective
Non-infective causes of epididymitis/orchitis, such as ischaemia, sarcoidosis and vasculitis, are rare.
Risk factors
The most common risk factor for epididymo-orchitis is UTI and its predisposing factors: 4-5
- Diabetes mellitus: including use of SGLT-2 inhibitors for treatment
- Incomplete bladder emptying: e.g from benign prostatic enlargement or urethral strictures
- Indwelling catheter
- Immunosuppression
Risk factors for infection caused by sexually transmitted infections (STI) include:
- Unprotected sexual intercourse
- Multiple sexual partners
- Men who have sex with men (MSM)
- Younger age
- Sex workers
Clinical features
History
Typical symptoms of epididymo-orchitis include:
- Acute onset
- Unilateral hemiscrotal pain
- Unilateral hemiscrotal swelling
- Unilateral hemiscrotal erythema
- Often longstanding/worsening lower urinary tract symptoms (e.g. frequency, urgency)
- Dysuria
- Urethritis and discharge in cases associated with STI
- Fever
- Systemic illness
Examination
A thorough testicular examination is required in suspected epididymo-orchitis.
Typical clinical findings of epididymo-orchitis include:4
- Scrotal skin thickening, induration and oedema
- Overlying erythema
- Firm, tender testis
- Irregular epididymis
- Reactive hydrocele
- May have palpable abscess
- Systemic signs of infection: fever, tachycardia, hypotension
Differential diagnoses
Other diagnoses to consider include:4, 6
- Testicular torsion: especially in the younger population with very acute onset unilateral testicular pain
- Torsion of the hydatid of Morgagni
- Trauma
- Testicular tumour
- Hydrocele
- Mumps: a cause of orchitis in children, especially with a decline in the MMR vaccination
Investigations
Bedside investigations
Relevant bedside investigations for epididymo-orchitis include:
- Basic observations: signs of systemic infection/septic shock
- Urinalysis: leucocytes and nitrites may be present
- Mid-stream sample of urine (MSSU): for microbiology, cultures and sensitivities, and urinary STI screen
Laboratory investigations
Relevant laboratory investigations for epididymo-orchitis include:
- Full blood count (FBC): may show raised white cell count
- CRP: may be raised
- Urea and electrolytes: renal function may be impaired
- Blood cultures: if signs of systemic infection
- Lactate: may be raised
Imaging
Radiological investigations can be useful in confirming the diagnosis or excluding complications such as testicular infarction or abscess, however, they are not required if the index of suspicion for epididymo-orchitis is high.
Relevant imaging includes:6
- Ultrasound with Doppler flow: can assess for the presence of an abscess and blood flow to the testicle
Diagnosis
Epididymo-orchitis is a clinical diagnosis formulated from the history and examination findings, supported by laboratory results and, sometimes, ultrasound.
Management
Most epididymo-orchitis cases can be treated successfully in the community without secondary care input. However, if the patient is clinically unwell, has persistent/worsening symptoms despite appropriate antimicrobial management, or there is a concern of testicular torsion, they will require urgent referral to urology.
Those who are septic or in septic shock should be appropriately managed with the sepsis six pathway and appropriate resuscitation as per local guidelines.
Conservative
Typical conservative management includes:
- Simple analgesia: such as ibuprofen and paracetamol
- Scrotal support or supportive underwear: can be used to aid analgesia
Medical
Typical medical management includes antimicrobials based on the most likely causative organism. Local guidelines should be followed.
Sexually transmitted infection
If an STI is the most likely source:5-6
- Refer to a local specialised sexual health clinic
- Intramuscular ceftriaxone 1 g injection as a single dose, plus oral doxycycline 100 mg twice daily for 14 days
- If cephalosporins/tetracyclines are contraindicated, oral ofloxacin 200 mg twice daily for 14 days
Sexually transmitted infection and/or enteric organism
If an STI and/or enteric organism is the most likely source (e.g. men who have insertive anal sex):6
- Intramuscular ceftriaxone 1 g, plus oral ofloxacin 200 mg twice daily for 14 days
- If a quinolone antibiotic is contraindicated, oral co-amoxiclav 500/125 mg three times daily for 10 days
Enteric organism
If an enteric organism is the most likely source:5-6
- Oral ofloxacin 200 mg twice daily for 14 days, or oral levofloxacin 500 mg once daily for 10 days.
- If a quinolones are contraindicated, oral co-amoxiclav 500/125 mg three times daily for 10 days
If IV antibiotics are required, prescribe empirically per local antimicrobial prescribing guidelines for lower urinary tract infection.
Risks of fluoroquinolones
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning about the risk of tendinopathy, peripheral neuropathy, and central nervous system adverse effects with fluoroquinolones (e.g ofloxacin, ciprofloxacin). Patients should be appropriately counselled on their risks, and clear safety netting information provided.
Surgical
Surgery is seldom required for simple epididymo-orchitis but can include:
- Surgical drainage: where abscess formation occurs, to achieve source control
- Orchidectomy: if severe epididymo-orchitis results in testicular infarction, the testicle can remain a source of infection with poor antibiotic penetrance, thus orchidectomy provides source control
Complications
If not treated promptly, or if significant risk factors are present, complications of epididymo-orchitis can include:
- Fourniers gangrene
- Sepsis
- Scrotal abscess
- Testicular infarction
- Chronic pain
- Infertility
Reviewer
Mr Xiang Wei Jonathan Lee
Urology ST7
Editor
Dr Jamie Scriven
References
- Çek M, Sturdza L, Pilatz A. Acute and Chronic Epididymitis. European Urology Supplements. 2017. Available from: [LINK].
- Delavierre D. Orchi-epididymitis. Annales d’Urologie. 2003. Available from: [LINK].
- Blandy J, Kaisary AV. Urology (Lecture Notes). Sixth Edition. Wiley–Blackwell. 2009.
- Reynard, S. Brewster, S. Biers. Oxford Handbook of Urology Third Edition. 2017
- European Association of Urology. Urological Infections. 2024. Available from: [LINK].
- NICE CKS. Epididymo-orchitis. 2024. Available from: [LINK].
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