Epididymo-orchitis
- Epididymitis is inflammation of the epididymis, usually caused by an infection. Epididymo-orchitis involves inflammation of the epididymis and testis
- Chlamydia trachomatis and Neisseria gonorrhoeae are the most likely cause of epididymo-orchitis in sexually active people of any age
- Consider enteric pathogens (e.g. Escherichia coli) in those older than 35 years, those who have had recent urinary tract instrumentation or surgery, or those who practice insertive anal sex
- Other possible causes of testicular swelling include: tumour, mumps, amiodarone use, Behçet disease (or syndrome), tuberculosis, brucellosis, Candida and cryptococcosis, with the latter particularly in those who are immunosuppressed
Symptoms |
Comments/Considerations |
Scrotal pain and swelling |
Usually unilateral. Swelling, induration and tenderness of the epididymis is the most common sign. If very acute onset or severe pain consider torsion and urgent surgical referral |
Dysuria or urethral discharge |
Urethral symptoms are often absent despite the presence of sexually transmitted infections (STIs) |
Suprapubic pain, frequency and nocturia |
Suggest urinary pathogen rather than STI |
- Scrotal pain and swelling +/- urethral discharge +/- dysuria
- Diagnosis is clinical, with support from the results of investigations undertaken
- Always consider the possibility of testicular torsion which is a surgical emergency and requires surgery within 6 hours of onset. Immediate urology referral indicated if suspected. Consider if:
- Sudden onset
- Severe pain
- Young age, particularly under 20 years
Investigations
- STI screening as per sexual health check guideline
- Mid-stream urine for microscopy, culture and sensitivities
Treat sexually active people with epididymo-orchitis presumptively for gonorrhoea and chlamydial infection
Treatment options
Infection |
Recommended |
|
If most likely due to an STI |
Ceftriaxone 500 mg in 2 mL of 1% lignocaine, intramuscular injection, as a single dose PLUS Doxycycline 100 mg orally, twice daily for 14 days |
|
If UTI pathogens suspected |
First line: amoxicillin/clavulanate 625 mg (500/125) orally, 3 times daily for 10 days Second line: cotrimoxazole 960 mg orally, twice daily for 10 days Modify treatment as needed, according to mid-stream urine result |
- For men who engage in insertive anal sex, treat empirically for STIs as above. If response is poor, alternative treatment may be required to treat enteric organisms
- Modify therapy based on the results of investigations and clinical response. In severe cases, treatment may need to be continued for up to 3 weeks. Seek specialist advice
- Bed rest, scrotal support and analgesia are commonly required. Complete resolution of the swelling may take several weeks, but a substantial response should occur in 4-5 days
- Refer to urology if patient systemically unwell or severe symptoms
- Advise to abstain from sex or use condoms for 2 weeks from the start of treatment, and until partner(s) tested and treated
NB. If urinary tract infection (UTI) pathogen, contact tracing is not required
- If sexual transmission is suspected, contact tracing is important to prevent re-infection and reduce transmission
- All sexual contacts in the last 3 months should be notified
- Most patients choose to tell contacts themselves; giving written information can be helpful
- Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence
Management of sexual contacts
- Contacts should have a sexual health check, and empirical treatment with doxycycline 100 mg orally twice daily for 7 days, assuming no allergies or contraindications
- Advise contacts to abstain from sex or use condoms until results are available, and treatment completed
- If index case or contacts test positive for an STI, see appropriate STI guideline for management
- Patient-delivered partner therapy is not legal in Aotearoa New Zealand
Mild epididymo-orchitis:
Moderate epididymo-orchitis:
If resolution slow, consider ultrasound scan to exclude complications or co-existing pathology e.g. testicular tumour Confirmed UTIs in men often require further investigation or urological referral – refer to local guidelines
|
Test of cure
|
Retesting
|
Referral to or discussion with a specialist is recommended for:
- Suspected testicular torsion (surgical emergency)
- Severe epididymo-orchitis
- Poor response to treatment
- Screening and treatment of sexual contacts if clinician wishes
- Allergy or contraindication to standard treatment options
- If STI-related, contact tracing is discussed in 100% of cases