Urology
This was previously featured in an exam
This was previously featured in an exam
Question 122 of 300
A 64 year old man presents to the Emergency Department with a 3 day history of scrotal pain and fever. On examination you find a normal appearing scrotum with normal testes. His left epididymis is exquisitely tender. What is the most likely organism to be causing this presentation?
Answer:
- This patient has epididymitis.
- In men 35 years of age or older, it is usually caused by enteric organisms (Escherichia coli or Enterococcus faecalis) that cause urinary tract infections, and may be associated with anatomical abnormalities of the urinary tract, or with recent urological instrumentation or catheterisation.
Epididymo-Orchitis
Urology
Last Updated: 27th April 2023
Epididymitis is characterised by acute unilateral pain and swelling. The pain usually begins at the epididymis and can spread to the entire testicle (epididymo-orchitis). Other symptoms include fever, erythema of the scrotal skin, and dysuria. Over half of men and boys with epididymitis also have orchitis. Isolated orchitis is rare — the commonest cause is mumps infection, although it can also be caused by other viral infections.
Causes
The aetiology and treatment of epididymitis and epididymo-orchitis are based on the person's age and the likely causative organisms:
- In pre-pubertal boys, it is often non-infective and self-limiting. The cause of inflammation is not known, although reflux of urine into the ejaculatory ducts is considered the most common cause in children younger than 14 years. However, it may also be caused by enteric organisms, such as Escherichia coli or Enterococcus faecalis that cause urinary tract infections, and may be associated with anatomical abnormalities of the urinary tract.
- In sexually active males aged 14-35 years, it is usually caused by sexually transmitted infections (Chlamydia trachomatis or Neisseria gonorrhoeae).
- In men 35 years of age or older, it is usually caused by enteric organisms (Escherichia coli or Enterococcus faecalis) that cause urinary tract infections, and may be associated with anatomical abnormalities of the urinary tract, or with recent urological instrumentation or catheterisation.
- In men who have penetrative anal intercourse, it may be caused by enteric organisms that cause urinary tract infections.
- Mumps infection can cause epididymo-orchitis at any age.
- Rare causes include adverse effect of amiodarone treatment (resolves once treatment stops), Behçet's syndrome, brucellosis, fungal infections, filariasis, Haemophilus influenzae, meningococcal infection, and tuberculosis.
Clinical features
- Onset is usually gradual over hours to days.
- The scrotum is usually unilaterally painful and tender (but painless and non-tender if tuberculous.)
- There is typically palpable tender swelling of the epididymis and/or testis, there may be erythema of scrotal skin.
- Presence of Prehn sign (relief of pain with elevation of the testes) may suggest epididymitis, but does not rule out testicular torsion.
- There may be urethral discharge, symptoms of a urinary tract infection, parotid swelling (mumps orchitis usually occurs 4–8 days after parotitis), or vomiting.
- There may be erythema or oedema of scrotum on the affected side, or a hydrocele.
- When tuberculous, the epididymis is hard with an irregular surface, the spermatic cord is thickened, and the vas deferens feels hard and irregular (like a string of beads).
Epididymo-orchitis may be difficult to distinguish from torsion. Torsion is particularly likely if: the person presents less than 6 hours after symptom onset; there is a history of previous trauma, previous pain attacks, nausea, or vomiting; the cremasteric reflex is absent; or the testis is elevated or lying transversely.
Assessment and management
- If symptoms are severe, the person is systemically unwell, or there is a suspected serious complication, arrange emergency hospital admission.
- If hospital admission is not needed, identify the most likely causative organism based on the person's age, urine dipstick test results, and risk factors to guide management.
- Assess the risk of a sexually transmitted infection (STI), such as chlamydia or gonorrhoea.
- Assess the risk of an enteric organism associated with lower urinary tract infection (UTI).
- Consider the possibility of other rare causes such as mumps orchitis, and manage appropriately.
- If an STI is the most likely cause, advise urgent referral to a local specialist sexual health clinic for STI testing, treatment, and possible contact tracing.
- If urgent referral to a local specialist sexual health clinic is not possible, start empirical antibiotic treatment. Advise the person to abstain from sexual contact until they and any partner(s) have completed treatment and follow up if there is a confirmed or suspected sexually transmitted infection (STI). Ideally follow up and contact tracing should be arranged by a local specialist sexual health clinic.
- If epididymo-orchitis is most likely due to any STI:
- Treat empirically with ceftriaxone 1 g intramuscular (IM) injection as a single dose, depending on local prescribing protocols, plus oral doxycycline 100 mg twice daily for 10–14 days.
- If epididymo-orchitis is most likely due to chlamydia or other non-gonococcal organisms (if no risk factors for gonorrhoea):
- Treat empirically with oral doxycycline 100 mg twice daily for 10–14 days, or oral ofloxacin 200 mg twice daily for 14 days.
- If epididymitis is most likely due to an STI and/or enteric organism (for example men who have insertive anal sex):
- Consider treating empirically with ceftriaxone 1 g IM, depending on local prescribing protocols, plus oral ofloxacin 200 mg twice daily for 14 days.
- If an enteric organism is the most likely cause:
- Ensure a urine dipstick test and mid-stream urine (MSU) sample for microscopy and culture have been arranged. A urine dipstick test positive for leucocytes and nitrites may suggest an enteric causative organism. A urine dipstick test positive for leucocytes only may suggest an STI causative organism.
- Consider treating empirically with oral ofloxacin 200 mg twice daily for 14 days, or oral levofloxacin 500 mg once daily for 10 days. If a quinolone antibiotic is contraindicated, treat with oral co-amoxiclav 500/125 mg three times a day for 10 days.
- Advise:
- Bed rest, scrotal elevation (such as with supportive underwear), and analgesia until symptoms improve.
- If symptoms worsen, or do not begin to improve within 3 days, return for reassessment.
Complications
Complications (usually of chronic disease, more commonly associated with uropathogen enteric organisms than sexually transmitted organisms) include:
- Chronic pain
- Reactive hydrocele
- Abscess formation
- Infarction of the testicle, testicular atrophy, and reduced fertility
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
