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Epididymitis/Orchitis, Emergency Medicine

Basics

Description

- Testis may become edematous owing to passive congestion or inflammation. - Resolution: - May be complete without sequelae - Peritubular fibrosis may develop, occluding ductules.

- Young men, age <35 yr: - Usually sexually transmitted - Chlamydia trachomatis (28-88%) with severe inflammation with minimal destruction - Neisseria gonorrhea (3-28%) - Coliform bacteria (7-24%): - Highly destructive with tendency for abscess - Coliform bacteria more common in insertive partners in anal intercourse

- Vasculitis: - Polyarteritis nodosa - Beh §et disease - Henoch-Sch ¶nlein purpura

- Coxsackie A and lymphocytic choriomeningitis virus - Granulomatous orchitis: Syphilis, mycobacterial and fungal diseases: - Fungal orchitis: - Blastomycosis in endemic regions - Invasive candidal infections in immunosuppressed hosts

- Disadvantages: - Highly examiner dependent - Difficult in infants or children

- Testicular scintigraphy: - Radionuclide study to assess perfusion - 90-100% sensitivity, 89-97% specificity in detecting testicular torsion - Inflammatory processes have increased flow and uptake. - Not routinely available at many institutions

Epididymitis

  • Definition: Inflammation or infection of the epididymis
  • Rare in prepubertal boys
  • Pathogenesis:Initial stages:Cellular inflammation begins in vas deferens, descends to epididymisAcute phase:Epididymis is swollen and indurated in upper and lower poles.Spermatic cord thickenedTestis may become edematous owing to passive congestion or inflammation.Resolution:May be complete without sequelaePeritubular fibrosis may develop, occluding ductules.
  • Complications:2/3 of men have atrophy due to partial vascular thrombosis of testicular artery.Abscess and infarction rare (5%)Incidence of infertility with unilateral epididymitis unknown:50% with bilateral epididymitis

Orchitis

  • Definition: Inflammation or infection of the testicle:Usually from direct extension of the same process within the epididymisIsolated testicular infection is rare:Can result from hematogenous spread of bacteria or following mumps infection
  • Categories:Pyogenic bacterial orchitis secondary to bacterial involvement of epididymisViral orchitis:Most commonly due to mumpsRare in prepubertal boys; occurs in 20-30% of postpubertal boys with mumps.Occurs 4-6 days after parotitis but can occur without parotitis.Unilateral in 70% of patientsUsually resolution in 6-10 days30-50% of testes involved have residual atrophy; rarely affects fertilityGranulomatous orchitis:SyphilisMycobacterium and fungal diseasesUsually occurs in immunocompromised host

Etiology

Epididymitis

  • Children:Most common in children <1 yr or between the ages of 12-15 yrEtiology identified in only 25% of prepubertal boysColiform or pseudomonal UTISexually transmitted diseases rare in prepubertal malesAssociated with predisposing abnormalities of lower urinary tract
  • Young men, age <35 yr:Usually sexually transmittedChlamydia trachomatis (28-88%) with severe inflammation with minimal destructionNeisseria gonorrhea (3-28%)Coliform bacteria (7-24%):Highly destructive with tendency for abscessColiform bacteria more common in insertive partners in anal intercourseUreaplasma urealyticum (sole organism in only 6% of cases)
  • Older men, age >35 yr:Commonly associated with underlying urologic pathology (benign prostatic hypertrophy, prostate cancer, strictures)May have acute or chronic bacterial prostatitisColiform bacteria more common (23-67%), especially after instrumentationC. trachomatis (8-80%)Klebsiella and Pseudomonas speciesN. gonorrhea (15%)Gram-positive cocci
  • Drug related:Amiodarone-induced epididymitis:Usually with amiodarone levels > therapeutic levels
  • Granulomatous:Etiology maybe related to mycobacterial, syphilis, or fungal infections:Mycobacterium tuberculosis is the most common cause of granulomatous disease affecting the epididymisSuspect in HIV patientsUrine cultures often negative for M. tuberculosis
  • Vasculitis:Polyarteritis nodosaBeh §et diseaseHenoch-Sch ¶nlein purpura

Orchitis

  • Pyogenic bacterial orchitis:Escherichia coliKlebsiella pneumoniaePseudomonas aeruginosaStaphylococciStreptococci
  • Viral orchitis:Mumps:20% may develop epididymo-orchitis.Rarely associated with live-attenuated mumps vaccine
  • Coxsackie A and lymphocytic choriomeningitis virus
  • Granulomatous orchitis: Syphilis, mycobacterial and fungal diseases:
  • Fungal orchitis:Blastomycosis in endemic regionsInvasive candidal infections in immunosuppressed hosts
  • Post-traumatic orchitis: Inflammation

Diagnosis

Signs and Symptoms

History

  • Gradual onset of mild to moderate testicular or scrotal pain, usually unilateral
  • Progressive scrotal swelling
  • Dysuria (30%):Recent UTIHistory of abnormal bladder function
  • Urethral discharge:Of patients with gonococcal epididymitis, 21-30% did not complain of urethral discharge.No demonstrable urethral discharge in 50%
  • Fever (14-28%)
  • Recent urethral instrumentation or catheterization

Physical Exam

  • Tenderness in groin, lower abdomen, or scrotum
  • Scrotal skin commonly erythematous and warm
  • Early:May feel swollen, indurated epididymis
  • Later:May not be able to distinguish epididymis from testisSpermatic cord may be edematous.
  • Intact cremasteric reflex
  • Prehn sign:Pain relief with testicular elevationCommonly observed but not specific
  • Coexistent prostatitis is rare (8%).
  • Pyogenic bacterial orchitis:Patients usually are acutely ill.FeverIntense discomfort, swelling of testicleOften reactive hydrocele

Essential Workup

  • Must differentiate from testicular torsion
  • Early consultation with urologist if strong suspicion of testicular torsion

Diagnosis Tests & Interpretation

Lab

  • CBC:Often leukocytosis in the range of 10,000-30,000/mm3
  • Urinalysis and culture:Positive leukocyte esterase on first-void urine or >10 WBC per high-power field on first-void urine sediment15-50% of patients with epididymo-orchitis have pyuria.24% of patients have positive urine bacterial cultures.
  • Urethral swab (50-73% have demonstrable urethritis despite minority of symptoms)Gram stain and culture or DNA amplification for C. trachomatis/N. gonorrheaAvoid bladder emptying within 2 hr of tests (lowers sensitivity).Especially for postpubertal and sexually active
  • Blood culture if systemically ill

Imaging

  • US: Color Doppler imaging:82-100% sensitivity, 100% specificity in detecting testicular torsion or decreased blood flowEpididymo-orchitis:HyperemiaIncreased vascularity and blood flowAdvantages:Can evaluate for epididymitis or other causes of scrotal pain70% sensitivity, 88% specificity for epididymitisDisadvantages:Highly examiner dependentDifficult in infants or children
  • Testicular scintigraphy:Radionuclide study to assess perfusion90-100% sensitivity, 89-97% specificity in detecting testicular torsionInflammatory processes have increased flow and uptake.Not routinely available at many institutions

Diagnostic Procedures/Surgery

Surgical exploration indications:

  • Scrotal abscess
  • If torsion cannot be excluded
  • Suspected or proved ischemia caused by severe epididymitis
  • Patient with solitary testicle
  • Scrotal fixation: Indicates severe inflammation and potential suppuration

Differential Diagnosis

  • Testicular torsion
  • Testicular tumor
  • Torsion of testicular appendages
  • Trauma to scrotum
  • Acute hernia
  • Acute hydrocele

Treatment

Pre-Hospital

  • IV access
  • IV fluids, especially if systemically ill

Initial Stabilization/Therapy

  • IV access
  • IV fluids, especially if systemically ill

Ed Treatment/Procedures

  • Antibiotics:Cover for chlamydial and gonococcal etiologies if adult or presumed sexually transmittedCover for coliform etiology:Child, or adult >35 yr of ageInsertive partner in anal intercoursePresumed nonsexually transmitted
  • Bed rest, scrotal support, ice packs
  • Analgesics and anti-inflammatories

Medication

  • Age <35 yr or sexually active postpubertal males:Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 10 days:May substitute azithromycin 1 g PO once for doxycycline if tetracycline allergyQuinolones no longer recommended if suspect N. gonorrhea
  • Age >35 yr or insertive partners in anal intercourse or negative culture/DNA amplification for C. trachomatis/N. gonorrhea or allergy to cephalosporins/tetracyclines:Ofloxacin 300 mg PO BID or levofloxacin 500 mg/d PO for 10 days
  • Bacterial epididymitis is uncommon in prepubertal boys and antibiotic regimens are not well established.
  • If concurrent UTI:TMP-SMX: 4 mg/kg TMP and 20 mg/kg SMX BID for 10 days
  • Avoid quinolones and tetracyclines in children

Follow-Up

Disposition

Admission Criteria

  • Surgical indications present
  • Older age group if it is the only way to ensure appropriate workup:Many will have underlying urologic pathology.
  • Systemically ill, fever, nausea, vomiting
  • Scrotal abscess
  • Intractable pain

Discharge Criteria

  • Fails to meet admission criteria
  • Patient with good follow-up
  • Able to take oral antibiotics

Issues for Referral

  • Children need workup for urologic abnormalities:Voiding cystourethrography, renal US
  • If bacteriuria present, exam of lower tract with cystoscopy after treatment completed

Follow-Up Recommendations

  • Failure to improve within 3 days of commencing antibiotics warrants urologic evaluation.
  • Persistence of symptoms after full antibiotic course warrants search for other causes of epididymitis:TB or fungal epididymitis, scrotal abscess, tumor, infarction.
  • Sexual partners of patients with suspected or confirmed C. trachomatis/N. gonorrhea should be tested/treated.
  • Children need urology consult for evaluation of structural urogenital abnormalities.

Pearls and Pitfalls

  • Testicular torsion should be ruled out in all cases of new-onset testicular pain.
  • Epididymitis usually due to STD in sexually active men <35 yr
  • Epididymitis usually due to coliform bacteria in men >35 yr
  • Antibiotic treatment is started immediately and empirically based on clinical picture.

Additional Reading

  • Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate. Available at www.uptodate.com. Accessed on January 30, 2013.
  • Ching CB, Sabanegh ES. Epididymitis. eMedicine. Available at emedicine.medscape.com/article/436154-overview. Accessed on January 30, 2013.
  • Tekg ¼l S, Riedmiller H, Gerharz E, et al. European Societyfor Paediatric Urology and European Association of Urology. Guidelines on paediatric urology. Available at http://www.uroweb.org/gls/pdf/19_Paediatric_Urology.pdf.
  • Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008;35(1):101-108.
  • Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.

See Also (Topic, Algorithm, Electronic Media Element)

  • Gonococcal Disease
  • Prostatitis
  • Testicular Torsion
  • Urethritis

Codes

ICD9

  • 604.90 Orchitis and epididymitis, unspecified
  • 604.91 Orchitis and epididymitis in diseases classified elsewhere
  • 604.99 Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess
  • 604.0 Orchitis, epididymitis, and epididymo-orchitis, with abscess
  • 072.0 Mumps orchitis
  • 604.9 Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess
  • 604 Orchitis and epididymitis

ICD10

  • N45.1 Epididymitis
  • N45.2 Orchitis
  • N45.3 Epididymo-orchitis
  • N45.4 Abscess of epididymis or testis
  • B26.0 Mumps orchitis
  • N45 Orchitis and epididymitis

SNOMED

  • 31070006 Epididymitis (disorder)
  • 274718005 Orchitis (disorder)
  • 197983000 Orchitis and epididymitis (disorder)
  • 27141002 Epididymo-orchitis with abscess (disorder)
  • 236766009 Gonococcal epididymitis (disorder)
  • 236771002 Mumps epididymo-orchitis (disorder)
  • 43491000 Acute epididymitis
  • 45082006 Acute orchitis (disorder)
  • 50390006 Non-specific granulomatous orchitis (disorder)