EPIDIDYMITIS ORCHITIS
Category: Urology
Abstract : Epididymitis and orchitis This is an inflammatory condition of the
epididymis, often involving the testis, and caused by bacterial infection. It
has a acute onsent and a clinical course lasting <6weeks. It presents with
pain, swelling, and tenderness of the epididymis. It should be distinguished
from chronic epididymitis where there is longstanding pain in the epididymis,
but usual
Epididymitis and orchitis
This is an inflammatory condition of the
epididymis, often involving the testis, and caused by bacterial infection. It
has a acute onsent and a clinical course lasting <6weeks. It presents with
pain, swelling, and tenderness of the epididymis. It should be distinguished
from chronic epididymitis where there is longstanding pain in the epididymis,
but usually no swelling.
Infection ascends from the urethra or bladder. In
men aged <35 years, the infective organism is usually N. gonorrhoeae, C.
trachomatis, or coliform bacteria (causing a urethritis which then ascends to
infect the epididymis). In children and older men, the infective organisms are
usually coliforms. Mycobacterium tuberculosis (TB) is a rarer cause the
epididymis feels like a beaded cord.
A rare, non-infective cause of
epididymitis is the antiarrhythmic drug amiodarone, which accumulates in high
concentrations within the epididymis, causing inflammation.10 It can be
unilateral or bilateral and resolves on discontinuation of the
drug.
Differential diagnosis
Torsion of the testicle is the main
differential diagnosis. A preceding history of symptoms suggestive of urethritis
or urinary infection (burning when passing urine, frequency, urgency, and
suprapubic pain) suggest that epididymitis is the cause of the scrotal pain, but
these symptoms may not always be present in epididymitis. In epididymitis pain,
tenderness and swelling may be confined to the epididymis, whereas in torsion,
the pain and swelling are localized to the testis. However, there may be overlap
in these physical signs.
Where doubt exists where you are unsure whether you
are dealing with a torsion or epididymitis exploration is the safest option.
Though radionuclide scanning can differentiate between a torsion and
epididymitis, this is not available in many hospitals. Colour doppler
ultrasonography, which provides a visual image of blood flow, can differentiate
between a torsion and epididymitis, but its sensitivity for diagnosing torsion
is only 80% (i.e. it misses the diagnosis in as many as 20% of cases these 20%
have torsion but normal findings on doppler ultrasonography of the testis). Its
sensitivity for diagnosing epididymitis is about 70%. Again, if in doubt,
explore.
Treatment of epididymitis
Culture urine, any urethral
discharge, and blood (if systemically unwell). This consists of bed rest,
analgesia, and antibiotics. Where C. trachomatis is a possible infecting
organism, prescribe a 10 - 14 day course of tetracycline 500mg 4 times a day or
doxycycline 100mg twice daily. If gonorrhoeae is confirmed on a gram stain of
the urethral discharge (if present) and on culture, prescribe ciprofloxacin
(though check the sensitivity on culture). For non-STD related epididymitis,
prescribe antibiotics empirically (until culture results are available)
according to your local microbiology department advice, which will be based on
local patterns of organisms isolated from urine cultures and on local patterns
of antibiotic resistance. Our empirical antibiotic regimen is ciprofloxacin for
2 weeks where there is no systemic upset. When the patient is systemically
unwell, we admit them for intravenous cefuroxime 1.5g tds and intravenous
gentamicin 5mg/kg until apyrexial, at which time we switch to oral ciprofloxacin
for 2 weeks.
Complications of acute epididymitis
These include abscess
formation, infarction of the testis, chronic pain, and
infertility.
Chronic epididymitis
is diagnosed in patients with
long-term pain in the epididymis and testicle. It can result from recurrent
episodes of acute epididymitis. Clinically, the epididymis is thickened and may
be tender. Treatment is with the appropriate antibiotics (guided by cultures),
or epididymectomy in severe cases.
Orchitis
is inflammation of the
testis, although it often occurs with epididymitis (epididymo-orchitis). Causes
include mumps; M. tuberculosis; syphilis; autoimmune processes (granulomatous
orchitis). The testis is swollen and tense, with oedema of connective tissues
and inflammatory cell infiltration. Treat the underlying cause.
Mumps
orchitis occurs in 30% of infected post-pubertal males. It manifests 3–4 days
after the onset of parotitis, and can result in tubular atrophy. 10–30% of
cases are bilateral and are associated with infertility.
Peri-urethral
abscess
This can occur in patients with urethral stricture disease, in
association with gonococcal urethritis and following urethral catheterization.
These conditions predispose to bacteria (gram-negative rods, enterococci,
anaerobes, gonococcus) gaining access through Buck's fascia to the peri-urethral
tissues. If not rapidly diagnosed and treated, infection can spread to the
perineum, buttocks, and abdominal wall.
The majority (90%) of patients
present with scrotal swelling and a fever. ~20% will have presented with urinary
retention, 10% with a urethral discharge, and 10% having spontaneoulsy
discharged the abscess through the urethra.
The abscess should be incised and
drained, a suprapubic catheter placed to divert the urine away from the urethra,
and broad spectrum antibiotics commenced (gentamicin and cefuroxime) until
antibiotic sensitivities are known.
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