Acute epididymo-orchitis is a common cause of testicular pain and swelling.
It is caused by acute inflammation of the epididymis (epididymitis) that may affect the testicle (orchitis). Most commonly the aetiology is infectious through the spread of pathogens from the urethra or bladder. It may be related to urinary tract infections or sexually transmitted infections.
Testicular torsion must be considered in anybody presenting with acute testicular pain, particularly in children, adolescents and younger men. If there is any diagnostic uncertainty, refer to urology / paediatric surgery.
Epididymo-orchitis is most commonly caused by sexually transmitted infections or urinary pathogens.
Sexually transmitted organisms tend to be considered in patients younger than 35, who have had previous STIs or are engaging in high-risk sexual activities. Urinary tract infection-related organisms tend to be considered in patients older than 35, particularly in the presence of risk factors like recent catheterisation or recurrent UTIs.
In pre-pubertal boys, epididymitis is commonly non-infective and self-limiting.
Patients will complain of testicular pain, signs of systemic infection may be present.
Consider signs and symptoms of potential underlying systemic illnesses that may cause epididymo-orchitis such as mumps and tuberculosis.
You MUST consider testicular torsion and refer urgently to urology if there is any suspicion.
Investigations should be aimed at revealing the underlying cause.
USS may confirm the diagnosis, showing inflammation of the epididymis. Reactive hydroceles may be present.
USS is also useful to exclude testicular tumours, another cause of testicular pain.
Antibiotics are used to treat suspected bacterial causes of epididymitis.
For the vast majority of patients, management is with antibiotics and symptomatic relief. Most can be managed on an outpatient basis but patients with signs of systemic or significant infection should be admitted for close monitoring and IV antibiotics.
NOTE: All patients being prescribed fluoroquinolones should be counseled on the risk of fluoroquinolone-induced tendon rupture. They should be avoided in patients with a history of tendon rupture related to quinolones or seizures.
Some patients develop features of systemic upset with acute epididymo-orchitis. This requires hospital admission and IV antibiotics as guided by the microbiology team.
The 'sepsis six' should be completed (ensure blood cultures are sent) as well as fluid resuscitation and monitoring as indicated.
Though rare, serious complications (testicular abscess, testicular infarction) may occur.
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