History

Fact Explanation
Gradual onset scrotal pain [1] Pain is classically localized to the posterior part of the testis and may even spread to the opposite testis[1]. Infection spreads from a primary infection of the urethra, prostrate or seminal vesicles to globus minus of the epididymis via the vas[2].Commonly occurs due to infection by Chlamydia trachomatis, Neisseria gonorrhoeae in men between 14-35 years and Coliforms such as E.coli in the younger age group.[3] Rarer causative pathogens are Ureaplasma and Mycobacterium, while cytomegalovirus or Cryptococcus in should be considered in the immunocompromised.
Scrotal swelling Occurs as a result of local inflammation or formation of a reactive hydrocele. Swelling follows the onset of pain[2]. Accompanied by erythema and tenderness.
Fever with chills Indicates bacterial etiology. May be associated with systemic symptoms such as malaise, lethargy, nausea or headache.
Dysuria A result of the infective etiology. May be accompanied by other lower urinary tract symptoms (LUTS) such as frequency, urgency or nocturia. [1]
Preceding mumps infection Commonest viral etiology of orchitis this is seen in 20 to 30 percent of men with mumps. [1] Presents with abrupt onset of pain and is unilateral. Can be complicated by infertility due to testicular atrophy[2]. May even occur in the absence of parotitis, especially in infants.
Unprotected intercourse In men between 14-35 years infection is commonly sexually transmitted. Among men who engage in insertive anal intercourse, coliform bacteria are common a cause. [1]
Bladder outflow obstruction Benign prostratic hyperplasia is an important risk factor in elderly males[1]. High pressure in the prostratic urethra may cause reflux of urine into the vas. [2] If an acute attack does not resolve fully in this setting may progress to chronic epididymoorchitis.
Discrete swelling of the lower pole of testis[2] Associated with mild pain. Seen in chronic epididymoorchitis due to tuberculosis. Epididymis feels craggy and even despite the testis being normal. [2]
Amiodarone use[4] Amiodarone is a recognized cause of non infectious epididymitis[4].
Catheterization or urethral instrumentation Introduces pathogenic flora to the urinary tract which spreads in a retrograde direction to cause infection of the epidydimis and testis.
Heavy lifting or straining Causes reflux of urine in to the vas deferens causing a chemical epidydimitis and may introduce pathogenic bacteria if there is a concurrent infection.
References
  1. TROJIAN Thomas, LISHNAK Timothy S,HEIMAN Diana. Epididymitis and Orchitis: An Overview. American Family Physician. 2009 April vol-1;79(7) 583-587. [viewed March 9 2014]. Available from: PMID: 19378875.
  2. RUSSELL RCG, WILLIAMS NORMAN S, BULSTRODE CHRISTOPHER JK. Bailey and Love's Short Practice of Surgery. 23rd Edition. London. Hodder and Arnold. 2000.
  3. WALKER NA, CHALLACOMBE B. Managing epididymo-orchitis in general practice. The Practioner. 2013 April Vol-257(1760) 21-5, 2-3.[ viewed 9 March 2014]. Available from: PMID: 23724748.
  4. IBSEN H H ,FRANDSEN F ,BRANDRUP F, MOLLER M.Epididymitis caused by treatment with amiodarone. Genitourinary Medicine. 1989 August vol- 65(4): 257–258.[viewed 10 March 2014]. Available from: PMC1194364

Examination

Fact Explanation
Unilateral scrotal swelling[1] Swelling of testis and epididymis can be combined with a reactive hydrocele and scrotal wall erythema[2].
Red, shiny scrotal skin[1] Initially scrotal skin is red due to the increased blood flow. Turns bronze over a few days and then the skin starts to desquamate[1].
Warm[1] Due to the increased blood flow in to the scrotal skin as a result of the inflammatory process.
Exquisite tenderness of testis and epididymis[3] The epididymis (located posterolateral to the testis) is tender and often indurated. Later, this may progress to testicular swelling (orchitis)[2]. If isolated tenderness of the testis likely to be due to a viral etiology.
Thickened spermatic cord[1] Usually accompanied by tenderness as the infection spreads distally from the urinary tract via the vas[1].
Tender prostrate and seminal vesicles[1] Prostratitis and seminal vesiculitis may spread to the epididymis and testis.[4]
Febrile[4] Due to the infective etiology of the disease. Patient will be very toxic and may have accompanying chills with high fever. A minority of patients who have non infective epidydimo-orchitis would not have this sign.
Prehn Sign Relief of pain with the elevation of the testis.[2]
References
  1. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. London. Hodder Arnold. 2005
  2. TROJIAN Thomas, LISHNAK Timothy S,HEIMAN Diana. Epididymitis and Orchitis: An Overview. American Family Physician. 2009 April vol-1;79(7) 583-587. [viewed March 9 2014]. Available from: PMID: 19378875.
  3. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK. Bailey and Love's Short Practice of Surgery. 23rd Edition. London. Hodder and Arnold. 2000.
  4. WEIN Alan J, KAVOUSSI Louis R, NOVICK Andrew C, PARTIN Alan W, and PETERS Craig A. Campbell-Walsh Urology. 10th edition. Elsevier. 2012.

Differential Diagnoses

Fact Explanation
Testicular torsion[1] Most important differential diagnosis that needs to be excluded. Has a shorter duration of pain when compared to epididymo-orchitis[2]. Highest incidence between 12-18 years[3]. Affected testis lies higher and in a more horizontal position in the scrotum[4]. Testis is exquisitely tender and palpation is difficult. Cremasteric reflex is absent and elevation of the testis makes pain worse[3]. If there is persistent doubt of the possibility of testicular torsion, doppler ultrasonographic scan can be performed.
Torsion of appendix testis[3] Abdominal pain. Testicular pain is minimal. Torted appendage may be palpable as a tender nodule. 'Blue dot sign'[3] may be present and indicates infarction. Usually accompanied by a reactive hydrocele.
Torsion of appendix epididymis[4] Presents with abdominal pain but minimal testicular tenderness[4].
Idiopathic scrotal edema[4] Skin and subcutaneous tissue of the scrotum become edematous, red and inflamed. No testicular or epididymal tenderness.
Strangulated inguino scrotal hernia [5] History of inguinal hernia. Features of bowel obstruction with vomiting and constipation. High pitched bowel sounds may be heard in the scrotum on auscultation.
Nephrotic syndrome[6] Should be considered in the pediatric age group. Presents with features of generalized edema such as peri-orbital edema, ascites, pleural effusion etc.
References
  1. WRIGHT JE, Acute epididymo-orchitis: with special reference to its differential diagnosis from torsion of the testis. Medical Journal of Australia. 1966 Jun 25 vol-1(26):1110-1.[viewed 9 March 2014] Available from: PMID: 5947537
  2. YU KJ, WANG TM, CHEN HW, WANG HH. The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis. Chang Gung Medical Journal. 2012 January February vol- 35(1) 38-45. [viewed 9 March 2014] Available from: PMID: 22483426.
  3. TROJIAN Thomas, LISHNAK Timothy S,HEIMAN Diana. Epididymitis and Orchitis: An Overview. American Family Physician. 2009 April vol-1;79(7) 583-587. [viewed March 9 2014]. Available from: PMID: 19378875.
  4. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. London. Hodder Arnold. 2005
  5. BUTLER JM, CHAMBERS J. An unusual complication of epididymo-orchitis: scrotal pyocele extending into the inguinal canal mimicking a strangulated inguinal hernia. The Journal of Emergency Medicine. 2008. Vol 35(4) 379-384. [Viewed 9 March 2014]. Available from: DOI: 10.1016/j.jemermed.2007.02.029
  6. Clinical Practice Guidelines. The Royal Children's Hospital Melbourne. [viewed 9 March 2014] Available from: http://www.rch.org.au/clinicalguide/guideline_index/Acute_Scrotal_Pain_or_Swelling/

Investigations - for Diagnosis

Fact Explanation
Urine Full Report[1] Should be performed on first-void mid stream urine sample. The presence of leukocyte esterase and white blood cells >10/hpf is suggestive of urethritis. This helps to differentiate epididymitis from testicular torsion.[1]
Urine gram stain[1] If intra cellular gram negative diplococci are demonstrable gonococcal urethritis is likely[2].
Urine culture and antibiogram[1] Should be performed on first void mid stream urine sample and swabs taken from urethral discharge[3]. Will show characteristic culture for gonococci[1].
Polymerase Chain Reaction (PCR) for Chlamydia trachomatis and Neisseria gonorrhoeae Should be done if there is suspicion of urethritis [1].
References
  1. TROJIAN Thomas, LISHNAK Timothy S,HEIMAN Diana. Epididymitis and Orchitis: An Overview. American Family Physician. 2009 April vol-1;79(7) 583-587. [viewed March 9 2014]. Available from: PMID: 19378875.
  2. Gonorrhea Laboratory Information. Centers for Disease Control and Prevention. October 2008. [viewed 10 March 2014] Available from: http://www.cdc.gov/std/gonorrhea/lab/ngon.htm
  3. WEIN Alan J, KAVOUSSI Louis R, NOVICK Andrew C, PARTIN Alan W, PETERS Craig A. Campbell-Walsh Urology. 10th edition. Elsevier. 2012.

Investigations - Followup

Fact Explanation
Culture and antibiogram of urine and urethral discharge Patients should be re-evaluated if symptoms fail to improve within 48 hours of initiation of treatment. Investigations performed for diagnosis should be re-done and possible causative organisms reconsidered[1].
References
  1. Sexually Transmitted Diseases 2010 Guidelines. Centers for Disease Control and Prevention. January 2011. Available from: http://www.cdc.gov/std/treatment/2010/epididymitis.htm

Management - General Measures

Fact Explanation
Bed rest[1] Will reduce the scrotal pain.
Supportive sling[1] Scrotum can be supported on an adhesive sling attached between the thighs[1]. Scrotum should rest on a pad of cotton wool.Reduces the pain due to elevation of the scrotum.
Anti pyretics Paracetamol can be prescribed for symptomatic management of fever.
Analgesics[2] NSAIDS, Coxibs and weak opioids can be used in the symptomatic management of scrotal pain.
References
  1. RUSSELL RCG, WILLIAMS NORMAN S, BULSTRODE CHRISTOPHER JK. Bailey and Love's Short Practice of Surgery. 23rd Edition. London. Hodder and Arnold. 2000.
  2. WEIN Alan J, KAVOUSSI Louis R, NOVICK Andrew C, PARTIN Alan W, PETERS Craig A. Campbell-Walsh Urology. 10th edition. Elsevier. 2012.

Management - Specific Treatments

Fact Explanation
Empirical anti-biotics Should be based on possible pathogens[1]. All patients should receive IM ceftriaxone (single dose) plus oral doxycycline (ten day regime). Fluoroquinolone ten day regime is advocated (levofloxacin or ofloxacin) if the infection is likely to be caused by enteric organisms. For men who are at risk for both sexually transmitted and enteric organisms (e.g., MSM who report insertive anal intercourse), ceftriaxone with a fluoroquinolone is recommended[2].
Continuing antibiotic therapy Antibiotics should be altered according to culture report and antibiogram. A floroquinolone should be added to the initial drugs if enteric organisms are suspected[2].
Management of sex partners[2] If acute epididymitis is suspected to be caused by N. gonorrhoeae or C. trachomatis sex partners should be evaluated and treated. Patients should abstain from sexual intercourse until their sex partners have received treatment[2].
Antibiotics for chronic epididymoorchitis A 4- to 6-week trial of antibiotics that is effective against possible organisms[3].
Epididymectomy Indicated in chronic epididymo-orchitis when all conservative measures have failed[3]. Will have a 50% percent chance of relieving the pain.
Epididymo-orchitis in HIV Should receive the same treatment regimen. Other etiologic agents such as CMV, salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium sp., Mycoplasma sp., and Mima polymorpha are also likely[2].
References
  1. TROJIAN Thomas, LISHNAK Timothy S,HEIMAN Diana. Epididymitis and Orchitis: An Overview. American Family Physician. 2009 April vol-1;79(7) 583-587. [viewed March 9 2014]. Available from: PMID: 19378875.
  2. Sexually Transmitted Diseases 2010 Guidelines. Centers for Disease Control and Prevention. January 2011. Available from: http://www.cdc.gov/std/treatment/2010/epididymitis.htm
  3. WEIN Alan J, KAVOUSSI Louis R, NOVICK Andrew C, PARTIN Alan W, PETERS Craig A. Campbell-Walsh Urology. 10th edition. Elsevier. 2012.