Epididymitis and Orchitis in Adults

👨‍⚕️ Epididymitis and orchitis are inflammatory conditions of the male genital tract. They may occur separately or together (epididymo-orchitis). Both can mimic testicular torsion, making careful assessment and urgent management essential.

🦠 Etiology

• Epididymitis (adults):
  • <35 yrs: Sexually transmitted → Chlamydia trachomatis, Neisseria gonorrhoeae
  • >35 yrs or urinary pathology: Gram-negative coliforms (e.g. E. coli), enterococci
  • Risk ↑ with catheters, prostate surgery, bladder outlet obstruction
• Orchitis:
  • Most commonly viral → mumps orchitis (post-pubertal males, often unilateral)
  • Bacterial orchitis usually secondary to epididymitis (extension of infection)

🩺 Clinical Features

• ⚡ Pain: Gradual onset scrotal pain & swelling (epididymitis); acute testicular pain in orchitis
• 🔥 Erythema & warmth of scrotum
• 🤒 Fever, chills, malaise (systemic features more common in orchitis)
• 💧 LUTS (dysuria, frequency, urgency) → typical in epididymitis with UTI organisms
• 📈 Prehn’s sign: Pain relief when elevating the testis (sometimes positive in epididymitis, not reliable)
• ❌ Rule out torsion if sudden onset, severe pain, absent cremasteric reflex

🔬 Diagnosis

• Labs: Urinalysis & culture; NAAT for gonorrhoea/chlamydia
• Bloods: FBC, CRP, U&E if septic/systemically unwell
• Imaging: Scrotal ultrasound + Doppler (↑ blood flow = epididymitis/orchitis; ↓ flow = torsion)
• Differentials: Testicular torsion, tumour, trauma

💊 Management

• Antibiotics:
  • STI-related (<35 yrs): Ceftriaxone 500 mg IM stat + Doxycycline 100 mg PO BD × 10–14 days
  • Non-STI (>35 yrs, UTI organisms): Levofloxacin 500 mg PO OD × 10–14 days or Ofloxacin 200–300 mg BD × 10–14 days
• Supportive: Bed rest, scrotal elevation, NSAIDs, ice packs
• Orchitis (viral/mumps): Supportive only — analgesia, scrotal support, rest
• Referral: If severe sepsis, abscess, diagnostic uncertainty, or failure to respond to antibiotics

⚠️ Complications

• Chronic epididymitis
• Scrotal abscess
• Testicular atrophy
• Infertility (especially bilateral orchitis or mumps orchitis)

🛡️ Prevention

• Safe sex practices (condoms, partner notification, STI screening)
• Prompt UTI treatment and catheter care
• Mumps vaccination (MMR) prevents viral orchitis

📊 Key Comparison: Epididymitis vs Orchitis

✅ Prognosis

• Excellent with early recognition and treatment
• Delayed diagnosis (esp. torsion vs infection confusion) → risk of testicular loss
• Bilateral orchitis (esp. mumps) may → infertility

3 Clinical Cases — Epididymitis & Orchitis in Adults 🩺🍒

• Case 1 — STI-associated epididymo-orchitis in a young man: A 22-year-old presents with 3 days of unilateral testicular pain, swelling, and dysuria. No fevers, but urethral discharge noted. Sexually active with new partner, no condom use. Exam shows tender, swollen left epididymis with preserved cremasteric reflex (distinguishes from torsion). Management: send urine NAAT for chlamydia/gonorrhoea, MSU for culture; start empirical therapy with ceftriaxone 1 g IM single dose + doxycycline 100 mg BD for 14 days (UK BASHH guideline). Advise STI screen and partner notification. Safety-net for worsening pain (exclude torsion), and review in 72 h.
• Case 2 — Coliform epididymo-orchitis in older man with LUTS: A 68-year-old with BPH presents with gradual right scrotal swelling, fever 38.2°C, dysuria, and incomplete emptying. Exam: tender epididymis, erythematous scrotal skin, PVR 250 mL. Management: MSU → likely E. coli; start oral fluoroquinolone (e.g., ciprofloxacin 500 mg BD 10–14 days) or trimethoprim depending on local resistance, adjust to sensitivities. Provide scrotal elevation and analgesia, optimise voiding (alpha-blocker), and consider catheter if retention. Monitor for abscess or sepsis; admit if systemically unwell.
• Case 3 — Mumps orchitis in a partially vaccinated adult: A 31-year-old man develops fever, parotid swelling, then bilateral testicular pain and swelling 5 days later. No urinary symptoms, UA negative. Exam: enlarged, tender testes, no discharge. Management: clinical diagnosis of mumps orchitis; isolate (droplet spread), supportive treatment with rest, NSAIDs, scrotal support, and hydration. Antibiotics not indicated. Counsel on potential infertility risk, particularly with bilateral disease. Notify public health team (notifiable disease) and check vaccination status in close contacts.