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Emergency And Acute Medicine - Epididymitis And Orchitis
Basic Overview
Epididymitis refers to inflammation or infection of the epididymis and is uncommon in prepubertal boys. The disease process typically begins with cellular inflammation in the vas deferens that descends into the epididymis. In the acute phase, the epididymis becomes swollen and indurated, often involving both upper and lower poles, with associated thickening of the spermatic cord. Secondary testicular edema may occur due to passive congestion or inflammatory spread. Resolution may be complete, though peritubular fibrosis can develop and lead to ductal obstruction. Testicular atrophy occurs in up to two thirds of affected men due to partial vascular thrombosis of the testicular artery. Abscess formation and infarction are uncommon. Infertility risk is uncertain with unilateral disease but approaches 50% with bilateral involvement.
Orchitis is defined as inflammation or infection of the testicle and most often results from direct extension of epididymal infection. Isolated orchitis is rare and may occur through hematogenous bacterial spread or viral infection, particularly mumps. Bacterial orchitis is typically pyogenic and secondary to epididymitis. Viral orchitis, most commonly due to mumps, occurs in 20–30% of postpubertal males with mumps infection, usually several days after parotitis, though it may occur independently. The disease is unilateral in most cases and usually resolves within 6–10 days, though residual testicular atrophy is common. Granulomatous orchitis is associated with syphilis, mycobacterial, or fungal infections and is more common in immunocompromised patients.
Causes And Predisposing Factors
In children, epididymitis is most common in infants younger than one year and adolescents aged 12–15 years. A specific etiology is identified in only a minority of prepubertal cases and often involves coliform or pseudomonal urinary tract infections, frequently associated with structural urinary abnormalities. Sexually transmitted infections are rare in this age group.
In men younger than 35 years, epididymitis is most often sexually transmitted. Chlamydia trachomatis is the most common pathogen, followed by Neisseria gonorrhoeae. Coliform bacteria are less common but tend to cause more destructive infections with higher risk of abscess formation, particularly in individuals engaging in insertive anal intercourse. Ureaplasma urealyticum may also be implicated.
In men older than 35 years, epididymitis is frequently associated with underlying urologic pathology such as benign prostatic hypertrophy, prostate cancer, or urethral strictures. Coliform organisms predominate, often following urinary tract instrumentation. Drug-induced epididymitis may occur with amiodarone, particularly at supratherapeutic levels. Granulomatous causes include tuberculosis, syphilis, and fungal infections, especially in patients with HIV. Vasculitic conditions such as polyarteritis nodosa, Behçet disease, and Henoch–Schönlein purpura are rare causes.
Orchitis may be caused by pyogenic bacteria such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, staphylococci, and streptococci. Viral causes include mumps and less commonly coxsackievirus and lymphocytic choriomeningitis virus. Granulomatous and fungal orchitis should be considered in immunocompromised hosts. Post-traumatic orchitis may occur due to inflammatory response following injury.
Clinical Presentation
Patients typically report gradual onset of unilateral scrotal or testicular pain that progresses over hours to days. Scrotal swelling and erythema are common. Dysuria may be present, often with a history of urinary tract infection or abnormal bladder function. Urethral discharge may be absent even in gonococcal infections. Fever occurs in a minority of cases. Recent urethral instrumentation or catheterization may be noted.
Physical Examination Findings
Examination often reveals tenderness in the groin, lower abdomen, or scrotum. The scrotal skin is frequently warm and erythematous. Early in the course, the epididymis may feel swollen and indurated, while later stages may make differentiation between epididymis and testis difficult. The spermatic cord may be edematous, and the cremasteric reflex is typically intact. Pain relief with testicular elevation may occur but is not diagnostic. Pyogenic orchitis is associated with acute systemic illness, marked testicular swelling, severe pain, fever, and often a reactive hydrocele.
Key Evaluation Priorities
Excluding testicular torsion is critical in all cases of acute scrotal pain. Immediate urologic consultation is required if torsion is suspected.
Diagnostic Studies And Interpretation
Laboratory evaluation may reveal leukocytosis. Urinalysis and urine culture may demonstrate pyuria or bacteriuria, though many patients have normal findings. Urethral testing for chlamydia and gonorrhea using nucleic acid amplification or culture is recommended in postpubertal and sexually active patients. Blood cultures are indicated in systemically ill individuals.
Color Doppler ultrasonography is the preferred imaging modality and demonstrates increased blood flow and hyperemia in epididymo-orchitis, helping to differentiate it from testicular torsion, which shows reduced or absent perfusion. Testicular scintigraphy may be used where available but is less commonly performed.
Alternative Diagnoses To Consider
The differential diagnosis includes testicular torsion, testicular tumor, torsion of testicular appendages, scrotal trauma, incarcerated hernia, acute hydrocele, and scrotal abscess.
Initial Management Approach
Prehospital and initial emergency department care includes intravenous access and fluid resuscitation for systemically ill patients.
Emergency Department Management
Treatment consists of empiric antibiotic therapy based on age and suspected etiology, along with bed rest, scrotal elevation, ice application, analgesics, and anti-inflammatory medications. Sexually transmitted causes should be covered in younger or sexually active patients, while coliform organisms should be targeted in older men or those with urinary tract pathology.
Medication Therapy
For sexually active men younger than 35 years, recommended therapy includes ceftriaxone intramuscularly combined with doxycycline for 10 days, with azithromycin as an alternative if doxycycline is contraindicated. For men older than 35 years, those with enteric organisms, or those unable to receive cephalosporins or tetracyclines, fluoroquinolones such as levofloxacin or ofloxacin are appropriate. In children with concurrent urinary tract infection, trimethoprim–sulfamethoxazole may be used, avoiding quinolones and tetracyclines.
Disposition And Follow-Up
Hospital admission is indicated for patients with suspected torsion, scrotal abscess, systemic illness, intractable pain, or inability to tolerate oral therapy. Stable patients with reliable follow-up may be discharged on oral antibiotics.
Follow-Up Guidance
Failure to improve within three days of initiating therapy requires urologic reassessment. Persistent symptoms after completion of antibiotics necessitate evaluation for alternative diagnoses such as tuberculosis, fungal infection, abscess, tumor, or infarction. Sexual partners should be evaluated and treated when sexually transmitted infection is suspected. Children require urologic evaluation for underlying structural abnormalities.
Clinical Insights And Common Errors
Testicular torsion must be excluded in all patients with acute scrotal pain. In sexually active men younger than 35 years, epididymitis is most commonly due to sexually transmitted pathogens, whereas coliform bacteria predominate in older men. Empiric antibiotic therapy should be initiated promptly based on clinical presentation.
Basic Overview
Epididymitis refers to inflammation or infection of the epididymis and is uncommon in prepubertal boys. The disease process typically begins with cellular inflammation in the vas deferens that descends into the epididymis. In the acute phase, the epididymis becomes swollen and indurated, often involving both upper and lower poles, with associated thickening of the spermatic cord. Secondary testicular edema may occur due to passive congestion or inflammatory spread. Resolution may be complete, though peritubular fibrosis can develop and lead to ductal obstruction. Testicular atrophy occurs in up to two thirds of affected men due to partial vascular thrombosis of the testicular artery. Abscess formation and infarction are uncommon. Infertility risk is uncertain with unilateral disease but approaches 50% with bilateral involvement.
Orchitis is defined as inflammation or infection of the testicle and most often results from direct extension of epididymal infection. Isolated orchitis is rare and may occur through hematogenous bacterial spread or viral infection, particularly mumps. Bacterial orchitis is typically pyogenic and secondary to epididymitis. Viral orchitis, most commonly due to mumps, occurs in 20–30% of postpubertal males with mumps infection, usually several days after parotitis, though it may occur independently. The disease is unilateral in most cases and usually resolves within 6–10 days, though residual testicular atrophy is common. Granulomatous orchitis is associated with syphilis, mycobacterial, or fungal infections and is more common in immunocompromised patients.
Causes And Predisposing Factors
In children, epididymitis is most common in infants younger than one year and adolescents aged 12–15 years. A specific etiology is identified in only a minority of prepubertal cases and often involves coliform or pseudomonal urinary tract infections, frequently associated with structural urinary abnormalities. Sexually transmitted infections are rare in this age group.
In men younger than 35 years, epididymitis is most often sexually transmitted. Chlamydia trachomatis is the most common pathogen, followed by Neisseria gonorrhoeae. Coliform bacteria are less common but tend to cause more destructive infections with higher risk of abscess formation, particularly in individuals engaging in insertive anal intercourse. Ureaplasma urealyticum may also be implicated.
In men older than 35 years, epididymitis is frequently associated with underlying urologic pathology such as benign prostatic hypertrophy, prostate cancer, or urethral strictures. Coliform organisms predominate, often following urinary tract instrumentation. Drug-induced epididymitis may occur with amiodarone, particularly at supratherapeutic levels. Granulomatous causes include tuberculosis, syphilis, and fungal infections, especially in patients with HIV. Vasculitic conditions such as polyarteritis nodosa, Behçet disease, and Henoch–Schönlein purpura are rare causes.
Orchitis may be caused by pyogenic bacteria such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, staphylococci, and streptococci. Viral causes include mumps and less commonly coxsackievirus and lymphocytic choriomeningitis virus. Granulomatous and fungal orchitis should be considered in immunocompromised hosts. Post-traumatic orchitis may occur due to inflammatory response following injury.
Clinical Presentation
Patients typically report gradual onset of unilateral scrotal or testicular pain that progresses over hours to days. Scrotal swelling and erythema are common. Dysuria may be present, often with a history of urinary tract infection or abnormal bladder function. Urethral discharge may be absent even in gonococcal infections. Fever occurs in a minority of cases. Recent urethral instrumentation or catheterization may be noted.
Physical Examination Findings
Examination often reveals tenderness in the groin, lower abdomen, or scrotum. The scrotal skin is frequently warm and erythematous. Early in the course, the epididymis may feel swollen and indurated, while later stages may make differentiation between epididymis and testis difficult. The spermatic cord may be edematous, and the cremasteric reflex is typically intact. Pain relief with testicular elevation may occur but is not diagnostic. Pyogenic orchitis is associated with acute systemic illness, marked testicular swelling, severe pain, fever, and often a reactive hydrocele.
Key Evaluation Priorities
Excluding testicular torsion is critical in all cases of acute scrotal pain. Immediate urologic consultation is required if torsion is suspected.
Diagnostic Studies And Interpretation
Laboratory evaluation may reveal leukocytosis. Urinalysis and urine culture may demonstrate pyuria or bacteriuria, though many patients have normal findings. Urethral testing for chlamydia and gonorrhea using nucleic acid amplification or culture is recommended in postpubertal and sexually active patients. Blood cultures are indicated in systemically ill individuals.
Color Doppler ultrasonography is the preferred imaging modality and demonstrates increased blood flow and hyperemia in epididymo-orchitis, helping to differentiate it from testicular torsion, which shows reduced or absent perfusion. Testicular scintigraphy may be used where available but is less commonly performed.
Alternative Diagnoses To Consider
The differential diagnosis includes testicular torsion, testicular tumor, torsion of testicular appendages, scrotal trauma, incarcerated hernia, acute hydrocele, and scrotal abscess.
Initial Management Approach
Prehospital and initial emergency department care includes intravenous access and fluid resuscitation for systemically ill patients.
Emergency Department Management
Treatment consists of empiric antibiotic therapy based on age and suspected etiology, along with bed rest, scrotal elevation, ice application, analgesics, and anti-inflammatory medications. Sexually transmitted causes should be covered in younger or sexually active patients, while coliform organisms should be targeted in older men or those with urinary tract pathology.
Medication Therapy
For sexually active men younger than 35 years, recommended therapy includes ceftriaxone intramuscularly combined with doxycycline for 10 days, with azithromycin as an alternative if doxycycline is contraindicated. For men older than 35 years, those with enteric organisms, or those unable to receive cephalosporins or tetracyclines, fluoroquinolones such as levofloxacin or ofloxacin are appropriate. In children with concurrent urinary tract infection, trimethoprim–sulfamethoxazole may be used, avoiding quinolones and tetracyclines.
Disposition And Follow-Up
Hospital admission is indicated for patients with suspected torsion, scrotal abscess, systemic illness, intractable pain, or inability to tolerate oral therapy. Stable patients with reliable follow-up may be discharged on oral antibiotics.
Follow-Up Guidance
Failure to improve within three days of initiating therapy requires urologic reassessment. Persistent symptoms after completion of antibiotics necessitate evaluation for alternative diagnoses such as tuberculosis, fungal infection, abscess, tumor, or infarction. Sexual partners should be evaluated and treated when sexually transmitted infection is suspected. Children require urologic evaluation for underlying structural abnormalities.
Clinical Insights And Common Errors
Testicular torsion must be excluded in all patients with acute scrotal pain. In sexually active men younger than 35 years, epididymitis is most commonly due to sexually transmitted pathogens, whereas coliform bacteria predominate in older men. Empiric antibiotic therapy should be initiated promptly based on clinical presentation.
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