Infections: Orchitis, & Epididymitis

Orchitis

Definitions

• Orchitis: inflammation of the testis
  • The term has been [inappropriately] used to describe testicular pain localized to the testis without objective evidence of inflammation
• Acute orchitis: sudden occurrence of pain and swelling of the testis associated with acute inflammation of that testis
• Chronic orchitis: inflammation and pain in the testis, usually without swelling, persisting for > 6 weeks

Classification

• Acute bacterial orchitis
  • Secondary to urinary tract infection
  • Secondary to sexually transmitted disease
• Non-bacterial infectious orchitis
  • Viral
    • most common cause of viral orchitis is mumps
  • Fungal
  • Parasitic
  • Rickettsial
• Non-infectious orchitis
  • Idiopathic
  • Traumatic
  • Autoimmune
• Chronic orchitis
• Chronic orchialgia
  • It may be impossible to clinically distinguish chronic orchitis from chronic orchialgia

Pathogenesis

• Orchitis (especially bacterial) usually occurs with epididymitis (secondary to local spread of an ipsilateral epididymitis) and are referred to as epididymo-orchitis.
  • In boys and elderly men, UTIs (including E. coli and Pseudomonas) are usually the underlying source.
  • In young sexually active men, sexually transmitted diseases are often responsible
  • Isolated orchitis without epididymitis is a relatively rare condition and is usually viral in origin, which spreads to the testis by a hematogenous route)
  • Mycobacterial infections, tuberculosis, and BCG therapy can also cause orchitis
• The process is usually unilateral; however, sometimes bilateral, especially if viral

Diagnosis and Evaluation

• Acute infectious orchitis
  • History: recent onset of testicular pain, often associated with abdominal discomfort, nausea, and vomiting. These symptoms may be preceded by symptoms of parotitis in boys or young men, by UTIs in boys or elderly men, or alternatively by symptoms of a sexually transmitted disease in sexually active men.
  • Physical exam may reveal a toxic and febrile patient
• Acute non-infectious orchitis
  • Similar presentation to acute infectious orchitis except that these patients lack the toxic appearance and fever
  • In the young patient, the most important differential diagnosis is torsion of the testis
• Chronic orchitis and orchialgia
  • May have a history of previous episodes of testicular pain, usually secondary to acute bacterial orchitis, trauma, or other causes.
  • The scrotum is not usually erythematous, but the testis may be somewhat indurated and is almost always tender to palpation.
• Labs
  • Urinalysis, urine microscopy, and urine culture
  • When a sexually transmitted disease is suspected, a urethral swab should be taken for culture
• Imaging
  • If the diagnosis is not evident from the history, physical examination, and these simple tests, scrotal ultrasonography should be performed (to rule out malignancy in patients with chronic orchitis or orchialgia).
  • Insert figure

Management

• General principles of therapy include bed rest, scrotal support, hydration, antipyretics, anti-inflammatory agents, and analgesics.
  • Treatment of chronic orchitis or orchialgia is supportive. Anti-inflammatory agents, analgesics, support, heat therapies, and nerve blocks all have a role in ameliorating symptoms.
• Antibiotic therapy (specific for UTIs, prostatitis, or sexually transmitted diseases) should be employed for infectious orchitis
  • If early testing findings are negative or results are unavailable, empirical treatment should be initiated, directed at the most likely pathogens based on the available clinical information; a fluoroquinolone would be the best agent in this scenario.
  • Orchitis resulting from Mycobacterium tuberculosis infection requires treatment with antituberculous drugs (rifampin, isoniazid, and pyrazinamide or ethambutol) and rarely surgery.
  • There are no specific anti-viral agents available to treat orchitis caused by mumps, and the previously mentioned supportive measures are important.
  • Abscess formation is rare; if it does occur, then percutaneous or open drainage is necessary
• Spermatic cord blocks with injection of a local anesthetic may sometimes be needed to relieve severe pain.
• Surgical intervention is rarely indicated, unless testicular torsion (or rarely xanthogranulomatous orchitis) is suspected; orchidectomy is indicated only in cases in which pain control is refractory to all other measures (and even this might not be successful in alleviating the chronic pain)

Epididymitis

Definitions

• Epididymitis: inflammation of the epididymis
• Acute epididymitis: sudden occurrence of pain and swelling of the epididymis associated with acute inflammation of the epididymis that lasts < 6 weeks
• Chronic epididymitis: inflammation and pain in the epididymis, usually without swelling (but with induration in long-standing cases), persisting > 6 weeks
  • Chronic infectious epididymitis is most commonly seen with tuberculosis, as a consequence of hematogenous spread rather than seeding of the urinary tract from the kidneys

Classification

1. Acute bacterial epididymitis
   • Secondary to UTI or sexually transmitted disease
2. Non-bacterial infectious epididymitis
   • Viral
   • Fungal
   • Parasitic
3. Non-infectious epididymitis
   • Idiopathic
   • Traumatic
   • Autoimmune
   • Amiodarone-induced
   • Associated with a known syndrome (e.g., Behçet disease)
4. Chronic epididymitis
5. Chronic epididymalgia

Causes

• Acute epididymitis
  • Usually results from the spread of infection from the bladder, urethra, or prostate via the ejaculatory ducts and vas deferens into the epididymis.
  • Source of infection and pathogen depends on population
    • In elderly males
      • Most common causes (3)
        1. BPH and associated stasis
        2. Urinary tract infection
        3. Catheterization
      • Most common pathogen in the pediatric and elderly age groups are the uropathogens with E. coli as the most common organism.
    • In sexually active males younger age < 35 who have sex with females
      • Commonly caused by sexually transmitted infection
      • Common pathogens: N. gonorrhoeae and C. trachomatis
    • Among males who have sex with males (MSM)
      • Can result from anal intercourse
      • Common pathogens: E. coli and Pseudomonas
• Chronic epididymitis (5)
  1. Inadequately treated acute epididymitis
  2. Recurrent epididymitis
  3. Tuberculosis
  4. Treatment with amiodarone
  5. Behçet disease
• Recurrent epididymitis
  • Risk factors (4)
    1. Meatal stenosis
    2. Urethral stricture
    3. Voiding dysfunction (high pressure voiding)
    4. Ectopic ureter

Diagnosis and Evaluation

• Must rule out testicular torsion, especially in younger patients
• History and Physical Exam
  • Physical Examination
    • Localizes the tenderness to the epididymis. However, in many cases the testis is also involved in the inflammatory process and subsequent pain; this is referred to as epididymo-orchitis. The spermatic cord is usually tender and swollen.
• Labs
  • Midstream urine specimen
  • Gram staining of a urethral smear
• Imaging
  • Scrotal ultrasonography
    • can be helpful but is not always diagnostic
• Insert figure

Management

• Empirical therapy is indicated before laboratory test results are available
  • Anti-inflammatory agents, analgesics, scrotal support, and nerve blocks have all been recommended as empirical treatment
• Acute bacterial epididymitis
  • EAU Guidelines on Urological Infections
    • If gonorrhea likely: ceftriaxone 1000mg IM/IV x 1 + doxycycline 200 mg initial dose by mouth and then 100 mg twice daily for ten to fourteen days
    • If gonorrhea unlikely (no urethral discharge): Doxycycline 200 mg initial dose by mouth and then 100 mg BID x 10-14 days plus an antibiotic active against Enterobacterales x 10-14 days
    • If non-sexually active: fluoroquinolone (levofloxacin) PO daily x 10-14 days
• Chronic epididymitis
  • 4- to 6-week trial of antibiotics that would potentially be effective against possible bacterial pathogens and particularly C. trachomatis may be appropriate.
• Surgical removal of the epididymis (epididymectomy) should be considered only when all conservative measures have been exhausted and the patient accepts that the operation will have at best a 50% chance of curing his pain

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 1, chap 13