eMedicine Specialties > Emergency Medicine > Genitourinary
Orchitis: Treatment & Medication
Updated: Jul 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Supportive treatment
- Bed rest
- Hot or cold packs for analgesia: Elevation of the scrotum and placement of ice on the affected testis are specific comfort measures that should be recommended to the patient with orchitis. The patient should put a small pillow or a towel between the legs to elevate the scrotum and place ice on the affected testis for 10-15 minutes, 4 times a day, until pain resolves.
- Most importantly, the ED physician must rule out testicular torsion, as the two syndromes often present with similar symptoms.5
- Second, the ED physician should consider epididymo-orchitis and, if highly suspected, treat appropriately.
Consultations
- If torsion is likely, urologic consultation is required for urgent surgical exploration.
- If a significant hydrocele is detected or suspected, urologic consultation is necessary to evaluate the need for a surgical tapping to relieve the pressure on the tunica.
- Follow-up care with a urologist is appropriate for an uncomplicated presentation of orchitis.
Medication
No medications are indicated for the treatment of viral orchitis.
Bacterial orchitis or epididymo-orchitis requires appropriate antibiotic coverage for suspected infectious agents. In patients with a bacterial etiology who are younger than 35 years and sexually active, antibiotic coverage for sexually transmitted pathogens (particularly gonorrhea and chlamydia) with ceftriaxone and either doxycycline or azithromycin is appropriate. Fluoroquinolones are no longer recommended by the Centers for Disease Control and Prevention (CDC) for treatment of gonorrhea because of resistance. For more information see, CDC updated gonococcal treatment recommendations (April 2007).
Patients older than 35 years with bacterial etiology require additional coverage for other gram-negative bacteria with a fluoroquinolone or TMP-SMX. Other appropriate medications include analgesics or antiemetics, as needed.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Used because of an increasing prevalence of penicillinase producing Neisseria gonorrhoeae.
Adult
125-250 mg IM once
Pediatric
<7 days: Not established
>7 days: 25-50 mg/kg/d IV; not to exceed 125 mg/d
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin (10% cross-sensitivity exists)
Doxycycline (Vibramycin, Doryx)
Inhibits protein synthesis and bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Used in combination with ceftriaxone for the treatment of gonorrhea.
Adult
100 mg PO bid for 7 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconlike syndrome may occur with outdated tetracyclines
Azithromycin (Zithromax)
Treats mild-to-moderate infections caused by susceptible strains of microorganisms.
Indicated for chlamydia and gonorrheal infections of the genital tract.
Adult
1 g PO once for chlamydial infections
2 g PO once for chlamydial and gonococcal infections
Pediatric
10 mg/kg PO once; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Commonly used in patients >35 y with orchitis.
Adult
160 mg TMP/800 mg SMZ PO q12h for 14 d
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg/kg/d, based on TMP, PO tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Ofloxacin (Floxin)
Penetrates prostate well and is effective against C trachomatis. A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. Used commonly in patients >35 y diagnosed with orchitis.
Adult
400 mg PO bid for 14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and consequently growth. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared. Used commonly in patients >35 y diagnosed with orchitis.
Adult
500 mg PO bid for 14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
More on Orchitis |
| Overview: Orchitis |
| Differential Diagnoses & Workup: Orchitis |
 Treatment & Medication: Orchitis |
| Follow-up: Orchitis |
| References |
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References
Herbener TE. Ultrasound in the assessment of the acute scrotum. J Clin Ultrasound. Oct 1996;24(8):405-21. [Medline].
Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63. [Medline].
Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. Jan 2001;8(1):90-93. [Medline].
Schalamon J, Ainoedhofer H, Schleef J, Singer G, Haxhija EQ, Hollwarth ME. Management of acute scrotum in children--the impact of Doppler ultrasound. J Pediatr Surg. Aug 2006;41(8):1377-80. [Medline].
Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. Nov 15 2008;78(10):1165-70. [Medline].
Basekim CC, Kizilkaya E, Pekkafali Z, Baykal KV, Karsli AF. Mumps epididymo-orchitis: sonography and color Doppler sonographic findings. Abdom Imaging. May-Jun 2000;25(3):322-5. [Medline].
Casella R, Leibundgut B, Lehmann K, Gasser TC. Mumps orchitis: report of a mini-epidemic. J Urol. Dec 1997;158(6):2158-61. [Medline].
Cook JL, Dewbury K. The changes seen on high-resolution ultrasound in orchitis. Clin Radiol. Jan 2000;55(1):13-8. [Medline].
Corbett HJ, Simpson ET. Management of the acute scrotum in children. ANZ J Surg. 2002;72(3):226-8. [Medline].
Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am. Aug 1988;6(3):521-46. [Medline].
Garthwaite MA, Johnson G, Lloyd S, Eardley I. The implementation of European Association of Urology guidelines in the management of acute epididymo-orchitis. Ann R Coll Surg Engl. Nov 2007;89(8):799-803. [Medline].
Gift TL, Owens CJ. The direct medical cost of epididymitis and orchitis: evidence from a study of insurance claims. Sex Transm Dis. Oct 2006;33(10 Suppl):S84-8. [Medline].
Lane TM, Hines J. The management of mumps orchitis. BJU Int. Jan 2006;97(1):1-2. [Medline].
Manson AL. Mumps orchitis. Urology. 2004;36(4):355-8. [Medline].
Masarani M, Wazait H, Dinneen M. Mumps orchitis. J R Soc Med. Nov 2006;99(11):573-5. [Medline].
Rosenstein D, McAninch JW. Urologic emergencies. Med Clin North Am. Mar 2004;88(2):495-518. [Medline].
Shafik A, El-Sibal O, Shafik I. Electro-orchidogram: a non-invasive diagnostic tool in testicular pathologies. Med Sci Monit. Aug 2006;12(8):MT51-5. [Medline].
Further Reading
Keywords
orchitis, viral orchitis, bacterial orchitis, epididymo-orchitis, mumps orchitis, testicular pain, testicular swelling, inflammation of the testis, viral mumps infection, epididymitis, testicular atrophy, benign prostatic hypertrophy, BPH, parotitis, testicular edema
