Epididymo-orchitis diagnosis and treatment

Last updated: August 2014

Diagnosis

Clinical

• Unilateral swelling and tenderness of epididymis, +/- testicle
• tender and swollen spermatic cord
• exclusion of testicular torsion
• fever
• hydrocele
• signs of urethritis in sexually-acquired epididymo-orchitis.

Microscopy, culture and urinalysis

Urethral swab

• Gram stain demonstrating >4 WBC per high power field, +/- gram negative intracellular diplococcic
• culture for gonorrhoea.

Urinalysis

• Dipstick presence of nitrites and leucocytes.

Mid stream specimen urine

• Microscopy, culture and sensitivities.

Nucleic Acid Amplification Test

• First void urine for chlamydia, gonorrhoea and mycoplasma genitalium.

Other laboratory tests

If systemically unwell

• full blood count, liver function, renal function, ESR, CRP
• mumps virus (mumps IgM/IgG serology).

If discrete testicular lump

• Alphafetoprotein
• Beta HCG.

If at risk

• specific testing for tuberculosis.

Radiological

Ultrasound of the scrotal contents.

Management

Empiric treatment should be commenced while awaiting test results.

Likely sexually transmitted pathogens including gonorrhoea

The following factors may be associated with the presence of a sexually transmitted pathogen

• younger age
• high risk sexual history
• urethral discharge present
• no previous urological procedure or urinary tract infection
• urine dipstick positive for leucocytes only.

Ceftriaxone 500 mg IMI diluted in 2ml of 1% lignocaine as a single dose followed by Ceftriaxone 500 mg daily IMI for 2 more doses if confirmed gonorrhoea (B1)

and

Azithromycin 1 g  orally as a single dose (B1)

plus

Doxycycline 100 mg orally 12 hourly for 14 days (D)

or

Azithromycin 1 g orally as a single dose one week later (B1)

Likely sexually transmitted pathogens (where gonorrhoea is absent or unlikely)

Doxycycline 100mg orally 12 hourly for 14 days (D)

or

Azithromycin 1gm as a single oral dose weekly for 2 doses (B1)

Likely enteric pathogens

The following factors may be associated with the presence of an enteric pathogen

• older age
• low risk sexual history
• no urethral discharge
• previous urological procedure or urinary tract infection
• urine dipstick positive for leucocytes and nitrites.

Trimethoprim 300mg orally daily for 14 days (B3)

or

Cephalexin 500mg orally 12 hourly for 14 days (A)

or

Amoxycillin + Clavulanate 500+125 mg orally 12 hourly for 14 days (B1)

or

Norfloxacin 400mg orally 12 hourly for 14 (B3)

Indications for hospitalisation

• severe pain suggesting other diagnoses (torsion, testicular infarction, abscess)
• unable or unlikely to comply with antimicrobial regimen
• high fever.

Epididymo-orchitis in HIV positive men

• consider atypical aetiological agents, including tuberculosis
• use same treatment regimens as for HIV negative men.

Patient education

The following points should be discussed:

• the nature of the condition
• abstinence from sex until therapy is completed and patient and partners no longer have symptoms
• advise on the side effects of medications
• full STI/HIV screening is recommended
• safer sex advice.

Contact tracing

All partners of men with confirmed sexually acquired epididymo-orchitis should be tested and treated accordingly.

Follow up

• Review at 48 hours.
• if no improvement re-evaluate diagnosis and therapy, consider admission
• persisting swelling and tenderness after completion of therapy require comprehensive evaluation
• all patients with urinary tract pathogen confirmed epididymo-orchitis should have further investigations of the urinary tract.

Further information

For further information on diagnosis and management of donovanosis contact Adelaide Sexual Health Centre.

Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Adelaide Sexual Health Centre staff and some flexibility is required in applying them to certain private practice situations.