Epididymoorchitis

Urology

Clinicals - History

Fact Explanation
Gradual onset scrotal pain Pain is classically localized to the posterior part of the testis and may even spread to the opposite testis. Infection spreads from a primary infection of the urethra, prostrate or seminal vesicles to globus minus of the epididymis via the vas.Commonly occurs due to infection by Chlamydia trachomatis, Neisseria gonorrhoeae in men between 14-35 years and Coliforms such as E.coli in the younger age group. Rarer causative pathogens are Ureaplasma and Mycobacterium, while cytomegalovirus or Cryptococcus in should be considered in the immunocompromised. Gradual onset scrotal pain
Pain is classically localized to the posterior part of the testis and may even spread to the opposite testis. Infection spreads from a primary infection of the urethra, prostrate or seminal vesicles to globus minus of the epididymis via the vas.Commonly occurs due to infection by Chlamydia trachomatis, Neisseria gonorrhoeae in men between 14-35 years and Coliforms such as E.coli in the younger age group. Rarer causative pathogens are Ureaplasma and Mycobacterium, while cytomegalovirus or Cryptococcus in should be considered in the immunocompromised.
Scrotal swelling Occurs as a result of local inflammation or formation of a reactive hydrocele. Swelling follows the onset of pain. Accompanied by erythema and tenderness. Scrotal swelling
Occurs as a result of local inflammation or formation of a reactive hydrocele. Swelling follows the onset of pain. Accompanied by erythema and tenderness.
Fever with chills Indicates bacterial etiology. May be associated with systemic symptoms such as malaise, lethargy, nausea or headache. Fever with chills
Indicates bacterial etiology. May be associated with systemic symptoms such as malaise, lethargy, nausea or headache.
Dysuria A result of the infective etiology. May be accompanied by other lower urinary tract symptoms (LUTS) such as frequency, urgency or nocturia. Dysuria
A result of the infective etiology. May be accompanied by other lower urinary tract symptoms (LUTS) such as frequency, urgency or nocturia.
Preceding mumps infection Commonest viral etiology of orchitis this is seen in 20 to 30 percent of men with mumps. Presents with abrupt onset of pain and is unilateral. Can be complicated by infertility due to testicular atrophy. May even occur in the absence of parotitis, especially in infants. Preceding mumps infection
Commonest viral etiology of orchitis this is seen in 20 to 30 percent of men with mumps. Presents with abrupt onset of pain and is unilateral. Can be complicated by infertility due to testicular atrophy. May even occur in the absence of parotitis, especially in infants.
Unprotected intercourse In men between 14-35 years infection is commonly sexually transmitted. Among men who engage in insertive anal intercourse, coliform bacteria are common a cause. Unprotected intercourse
In men between 14-35 years infection is commonly sexually transmitted. Among men who engage in insertive anal intercourse, coliform bacteria are common a cause.
Bladder outflow obstruction Benign prostratic hyperplasia is an important risk factor in elderly males. High pressure in the prostratic urethra may cause reflux of urine into the vas. If an acute attack does not resolve fully in this setting may progress to chronic epididymoorchitis. Bladder outflow obstruction
Benign prostratic hyperplasia is an important risk factor in elderly males. High pressure in the prostratic urethra may cause reflux of urine into the vas. If an acute attack does not resolve fully in this setting may progress to chronic epididymoorchitis.
Discrete swelling of the lower pole of testis Associated with mild pain. Seen in chronic epididymoorchitis due to tuberculosis. Epididymis feels craggy and even despite the testis being normal. Discrete swelling of the lower pole of testis
Associated with mild pain. Seen in chronic epididymoorchitis due to tuberculosis. Epididymis feels craggy and even despite the testis being normal.
Amiodarone use Amiodarone is a recognized cause of non infectious epididymitis. Amiodarone use
Amiodarone is a recognized cause of non infectious epididymitis.
Catheterization or urethral instrumentation Introduces pathogenic flora to the urinary tract which spreads in a retrograde direction to cause infection of the epidydimis and testis. Catheterization or urethral instrumentation
Introduces pathogenic flora to the urinary tract which spreads in a retrograde direction to cause infection of the epidydimis and testis.
Heavy lifting or straining Causes reflux of urine in to the vas deferens causing a chemical epidydimitis and may introduce pathogenic bacteria if there is a concurrent infection. Heavy lifting or straining
Causes reflux of urine in to the vas deferens causing a chemical epidydimitis and may introduce pathogenic bacteria if there is a concurrent infection.

Clinicals - Examination

Fact Explanation
Unilateral scrotal swelling Swelling of testis and epididymis can be combined with a reactive hydrocele and scrotal wall erythema. Unilateral scrotal swelling
Swelling of testis and epididymis can be combined with a reactive hydrocele and scrotal wall erythema.
Red, shiny scrotal skin Initially scrotal skin is red due to the increased blood flow. Turns bronze over a few days and then the skin starts to desquamate. Red, shiny scrotal skin
Initially scrotal skin is red due to the increased blood flow. Turns bronze over a few days and then the skin starts to desquamate.
Warm Due to the increased blood flow in to the scrotal skin as a result of the inflammatory process. Warm
Due to the increased blood flow in to the scrotal skin as a result of the inflammatory process.
Exquisite tenderness of testis and epididymis The epididymis (located posterolateral to the testis) is tender and often indurated. Later, this may progress to testicular swelling (orchitis). If isolated tenderness of the testis likely to be due to a viral etiology. Exquisite tenderness of testis and epididymis
The epididymis (located posterolateral to the testis) is tender and often indurated. Later, this may progress to testicular swelling (orchitis). If isolated tenderness of the testis likely to be due to a viral etiology.
Thickened spermatic cord Usually accompanied by tenderness as the infection spreads distally from the urinary tract via the vas. Thickened spermatic cord
Usually accompanied by tenderness as the infection spreads distally from the urinary tract via the vas.
Tender prostrate and seminal vesicles Prostratitis and seminal vesiculitis may spread to the epididymis and testis. Tender prostrate and seminal vesicles
Prostratitis and seminal vesiculitis may spread to the epididymis and testis.
Febrile Due to the infective etiology of the disease. Patient will be very toxic and may have accompanying chills with high fever. A minority of patients who have non infective epidydimo-orchitis would not have this sign. Febrile
Due to the infective etiology of the disease. Patient will be very toxic and may have accompanying chills with high fever. A minority of patients who have non infective epidydimo-orchitis would not have this sign.
Prehn Sign Relief of pain with the elevation of the testis. Prehn Sign
Relief of pain with the elevation of the testis.

Investigations - Diagnosis

Fact Explanation
Urine Full Report Should be performed on first-void mid stream urine sample. The presence of leukocyte esterase and white blood cells >10/hpf is suggestive of urethritis. This helps to differentiate epididymitis from testicular torsion. Urine Full Report
Should be performed on first-void mid stream urine sample. The presence of leukocyte esterase and white blood cells >10/hpf is suggestive of urethritis. This helps to differentiate epididymitis from testicular torsion.
Urine gram stain If intra cellular gram negative diplococci are demonstrable gonococcal urethritis is likely. Urine gram stain
If intra cellular gram negative diplococci are demonstrable gonococcal urethritis is likely.
Urine culture and antibiogram Should be performed on first void mid stream urine sample and swabs taken from urethral discharge. Will show characteristic culture for gonococci. Urine culture and antibiogram
Should be performed on first void mid stream urine sample and swabs taken from urethral discharge. Will show characteristic culture for gonococci.
Polymerase Chain Reaction (PCR) for Chlamydia trachomatis and Neisseria gonorrhoeae Should be done if there is suspicion of urethritis . Polymerase Chain Reaction (PCR) for Chlamydia trachomatis and Neisseria gonorrhoeae
Should be done if there is suspicion of urethritis .

Investigations - Management

Fact Explanation
Culture and antibiogram of urine and urethral discharge Patients should be re-evaluated if symptoms fail to improve within 48 hours of initiation of treatment. Investigations performed for diagnosis should be re-done and possible causative organisms reconsidered. Culture and antibiogram of urine and urethral discharge
Patients should be re-evaluated if symptoms fail to improve within 48 hours of initiation of treatment. Investigations performed for diagnosis should be re-done and possible causative organisms reconsidered.

Management - Supportive

Fact Explanation
Bed rest Will reduce the scrotal pain. Bed rest
Will reduce the scrotal pain.
Supportive sling Scrotum can be supported on an adhesive sling attached between the thighs. Scrotum should rest on a pad of cotton wool.Reduces the pain due to elevation of the scrotum. Supportive sling
Scrotum can be supported on an adhesive sling attached between the thighs. Scrotum should rest on a pad of cotton wool.Reduces the pain due to elevation of the scrotum.
Anti pyretics Paracetamol can be prescribed for symptomatic management of fever. Anti pyretics
Paracetamol can be prescribed for symptomatic management of fever.
Analgesics NSAIDS, Coxibs and weak opioids can be used in the symptomatic management of scrotal pain. Analgesics
NSAIDS, Coxibs and weak opioids can be used in the symptomatic management of scrotal pain.

Management - Specific

Fact Explanation
Empirical anti-biotics Should be based on possible pathogens.
All patients should receive IM ceftriaxone (single dose) plus oral doxycycline (ten day regime). Fluoroquinolone ten day regime is advocated (levofloxacin or ofloxacin) if the infection is likely to be caused by enteric organisms.
For men who are at risk for both sexually transmitted and enteric organisms (e.g., MSM who report insertive anal intercourse), ceftriaxone with a fluoroquinolone is recommended.
Empirical anti-biotics
Should be based on possible pathogens.
All patients should receive IM ceftriaxone (single dose) plus oral doxycycline (ten day regime). Fluoroquinolone ten day regime is advocated (levofloxacin or ofloxacin) if the infection is likely to be caused by enteric organisms.
For men who are at risk for both sexually transmitted and enteric organisms (e.g., MSM who report insertive anal intercourse), ceftriaxone with a fluoroquinolone is recommended.
Continuing antibiotic therapy Antibiotics should be altered according to culture report and antibiogram. A floroquinolone should be added to the initial drugs if enteric organisms are suspected. Continuing antibiotic therapy
Antibiotics should be altered according to culture report and antibiogram. A floroquinolone should be added to the initial drugs if enteric organisms are suspected.
Management of sex partners If acute epididymitis is suspected to be caused by N. gonorrhoeae or C. trachomatis sex partners should be evaluated and treated.
Patients should abstain from sexual intercourse until their sex partners have received treatment.
Management of sex partners
If acute epididymitis is suspected to be caused by N. gonorrhoeae or C. trachomatis sex partners should be evaluated and treated.
Patients should abstain from sexual intercourse until their sex partners have received treatment.
Antibiotics for chronic epididymoorchitis A 4- to 6-week trial of antibiotics that is effective against possible organisms. Antibiotics for chronic epididymoorchitis
A 4- to 6-week trial of antibiotics that is effective against possible organisms.
Epididymectomy Indicated in chronic epididymo-orchitis when all conservative measures have failed. Will have a 50% percent chance of relieving the pain. Epididymectomy
Indicated in chronic epididymo-orchitis when all conservative measures have failed. Will have a 50% percent chance of relieving the pain.
Epididymo-orchitis in HIV Should receive the same treatment regimen. Other etiologic agents such as CMV, salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium sp., Mycoplasma sp., and Mima polymorpha are also likely. Epididymo-orchitis in HIV
Should receive the same treatment regimen. Other etiologic agents such as CMV, salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium sp., Mycoplasma sp., and Mima polymorpha are also likely.

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