■ Swelling, scrotal erythema, pain
■ pain is usually unilateral, but can be bilateral and starts with the tail at the lower pole of the epididymis, spreading towards the head and upper pole of the epididymis, sometimes causing inflammation of the testis itself
■ swelling (+/- secondary hydrocoele) can make examination and differential diagnosis difficult.
If torsion / tumour difficult to exclude refer (but consider STI testing and giving antibiotics also
■ If STI urethritis is the cause
■ there may be associated dysuria / urethral discharge, but sometimes the urethritis has no Sx
■ If UTI is the cause
■ there may be associated UTI Sx
■ Torsion – the most important differential diagnosis! (Delay > 6 hours infarction)
■ more likely if < 20 years old, sudden onset of pain
■ if you cannot fully exclude this urgent urology referral
■ Tumour
■ 1/4 tumours present with pain
■ refer
■ Mumps orchitis
■ Commonest complication of mumps in post-pubertal men, affecting 20 to 30% cases2
■ Initial headache, fever … unilateral / bilateral parotid swelling... 7 to 10d later: unilateral testicular swelling.
But
– 30 to 40% pts with mumps do not develop parotitis2 – Scrotal Sx can occur without systemic Sx
■ Tuberculosis
■ Subacute / chronic onset of scrotal swelling +/- pain , +/- systemic Sx of TB
9. Epididymo-orchitis
Management
History taking is vital
■ Suspicion of torsion / tumour Urology. But always test for STIs and consider offering empirical antibiotics prior to referral
■ STIs must always be excluded. STI more likely if...
■ younger age, sexual activity, no UTI Sx
■ urethral discharge
■ urine dipstick neg (or +ve for leucocytes only)
■ in MSM
■ UTIs should also be excluded. UTI more likely if...
■ older age, low risk sexual Hx, previous UTI / instrumentation
■ no urethral discharge
■ urine dipstick +ve for leucocytes and nitrites
In general...
Consider immediate referral to GUM for thorough investigations.
If this is not possible
■ check for urethritis
■ Sx and signs?
■ Consider looking for threads in 1st pass urine (see Male Urethritis chapter)
■ test for Chlamydia (NAAT) and gonorrhoea (NAAT or culture) – in those with higher risk of GC you should ideally test for both NAAT and GC culture
■ urine dipstick +/- MSU
9. Epididymo-orchitis
Treatment
1. ? STI NB:
■ Whilst GPs can test for most STIs, the problem is not being able to diagnose possible gonorrhoea ‘instantly’ on microscopy. This affects your immediate management, because although gonococcal epididymitis is rare, the Rx is different to non-gonococcal cases.
■ GP clues for possible gonococcal epididymitis
■ known contact of gonorrhoea
■ particularly severe Sx (Eg: purulent urethral discharge) although you can’t always tell
■ being a member of a higher risk group for gonorrhoea3 (young adults / urban areas / MSM / black ethnic minority populations)
■ With increasing antibiotic resistance to gonorrhoea, it is vital that correct management for gonorrhoea is followed (see gonorrhoea chapter). Basically
■ Culture should be taken prior to Rx so antibiotic sensitivity can be monitored
■ All +ve cases need a test of cure after Rx
■ 1st-line Rx is an im injection plus oral Rx
■ All Rx failures must be reported to the HPA
■ Partners must be traced and Rx’d
■ Pragmatically, therefore, it may be easier to refer urgently to GUM. If not possible, then...
■ If high suspicion of non-gonoccal STI cause, give (there and then in surgery, after tests have been taken and before results are back )…
■ DOXYCLINE 100 mg po bd 14/7 (consider NSAIDS as well) or
■ OFLOXACIN 200 mg po bd 14/7 (avoid NSAIDS – interact with Quinolones)
■ If you suspect gonococcal epididymitis, refer to GUM.
If this is very difficult (although referral pathways should be in place) then commence Rx there and then in surgery, after tests have been taken and before results are back:
■ CEFTRIAXONE 500 mg im injection stat, plus DOXYCYCLINE 100 mg po bd 14/7
■ i.m injections are difficult for most GPs to organize in surgery. If this is so, d/w GUM.
Ofloxacin may be used but it is vital that sensitivity testing (ie: culture, not NAAT) is taken first (NB: ciprofloxacin does not effectively treat Chlamydia)
■ Ensure prompt appropriate delivery of the swab to the lab for culture
■ See gonorrhoea chapter for background information
In general
■ As with all STI management, advise patient no sexual contact during Rx and until partner(s) treated
■ Consider referral to GUM for partner notification
■ Screen for other STIs (minimum HIV, syphilis, Chlamydia, gonorrhoea)
■ See STI standards chapter
9. Epididymo-orchitis
See national STI Management
Standards:
Chapter 1
2. ?UTI
■ If Hx , examination and urine dipstick suggestive, treat as for complicated UTI:
■ Rx: local prescribing policy (eg: OFLOXACIN 200 mg po bd for 14/7)
■ Confirmed UTI cause? urinary tract should be investigated further
3. Others
■ TB
■ Three early morning urines for AAFBs, chest X ray, etc
■ Seek specialist advice
■ Mumps2
■ Diagnosed by mumps IgM/IgG serology
■ Of affected testicles, up to 50% show a degree of testicular atrophy
■ Rarely leads to sterility but may contribute to sub-fertility
■ Rx: self limiting therefore supportive Rx (rest, NSAIDs, etc). Steroids may pain and oedema but do not alter clinical course
General advice
■ rest. Sometimes Sx are severe enough to warrant a sick (fit) note
■ scrotal elevation / supportive underwear
■ follow up in 3 days to check Sx resolving (arrange to see sooner if Sx worsen)
■ if not improving, reassess diagnosis and Rx
■ Sx should be considerably better at end of Rx
■ If better, check all results.
– If STI, check compliance with Rx and partner notification – If UTI investigate urinary tract and refer to urology
■ If no better, consider alternative diagnosis / ultrasound scan / consider urology referral
References
1. 2010 UK National Guideline for the management of epididymo-orchitis BASHH Clinical Effectiveness Group
available at www.bashh.org/guidelines 2. Mumps orchitis
Masarani et al
J R Soc Med. 2006 Nov; 99 (11):573–5.
3. Health Protection Agency data Available at www.hpa.org.uk
9. Epididymo-orchitis
Background
1, 2■ Genital Chlamydia is the condition of being infected with Chlamydia trachomatis, a bacterial species within the genus Chlamydia
■ The classification is complex, but basically there are 3 species of Chlamydia that cause disease in humans (table 1)
■ C trachomatis is an obligate intracellular pathogen with a lifecycle of 48 to 72 hours.
■ Main sites of infection are the mucous membranes of the urethra, endocervix, rectum, pharynx, and conjunctiva.
■ Can be asymptomatic at all these sites (and uncertain how long for)
■ Transmission is by direct inoculation of infected secretions from one mucous membrane to another.
Epidemiology
2,3■ Commonest bacterial STI in the UK: highest incidence in young adults.
■ Approx 3 to 7% of sexually active women under the age of 24 and men aged between 20 to 24 may be currently infected. See Health Protection Agency website for latest statistics www.hpa.org
■ 2/3 of sexual partners of Chlamydia +ve individuals will also be Chlamydia +ve
■ Risk factors for infection
■ Age under 25
■ More than 1 partner in the last year, or a recent new sexual partner (the latter is more significant)
■ Lack of consistent use of condoms
■ Untreated infections may persist for > 1 year (in 50% people). About 95% will clear spontaneously after 4 years.
Latent long-term persistence is possible.
10. Chlamydia
Table 1
Species Serovar Natural host Human disease
C. psittaci multiple Birds, lower mammals Psittacosis
C. pneumoniae TWAR Humans Respiratory disease
C.trachomatis A, B, C Humans Hyperendemic trachoma
D – K Humans Genital infection, proctitis,
conjunctivitis, sexually acquired reactive arthritis
L1, L2, L3 Humans Lymphogranuloma venereum
See national STI Management
Standards:
Chapter 1