Orchitis 

Updated: Aug 16, 2017
Author: Nataisia Terry, MD; Chief Editor: Erik D Schraga, MD 

Overview

Practice Essentials

Orchitis is an acute inflammatory reaction of the testis secondary to infection. Most cases are associated with a viral mumps infection; however, other viruses and bacteria can cause orchitis. Testicular examination reveals the following: testicular enlargement, induration of the testis, tenderness, erythematous scrotal skin, edematous scrotal skin, and enlarged epididymis associated with epididymo-orchitis. On rectal examination, there is a soft boggy prostate (prostatitis). often associated with epididymo-orchitis.[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]

Orchitis most commonly occurs with epididymitis. Epididymitis is usually bacterial in origin; the most common pathogen is Neisseria gonorrhoeae in men aged 14-35 years, and Escherichia coli is the most common cause in boys younger than 14 years and in men older than 35 years. Viral orchitis is most often caused by mumps infection but can also be caused by a nonspecific inflammatory process in the testes.

Approximately 20% of prepubertal patients (younger than 10 years) with mumps develop orchitis. Unilateral testicular atrophy occurs in 60% of patients with orchitis.[16]  Sterility is rarely a consequence of unilateral orchitis.Despite some anecdotal reports, little evidence supports an increased likelihood of developing a testicular tumor after an episode of orchitis.

The symptoms of orchitis usually present several days after parotitis. Isolated bacterial orchitis is even more rare and is usually associated with a concurrent epididymitis; it occurs in sexually active males older than 15 years or in men older than 50 years with benign prostatic hypertrophy (BPH). Symptoms of isolated orchitis usually resolve spontaneously in approximately 3-10 days, whereas epididymitis will usually resolve in a similar time frame after initiation of antibiotic treatment.

In sexually active males, urethral cultures and gram stain should be obtained for Chlamydia trachomatis and Neisseria gonorrhoeae. Urinalysis and urine culture should also be obtained.

Supportive treatment includes bed rest, hot or cold packs for analgesia, and scrotal elevation. With appropriate antibiotic coverage, most cases of bacterial orchitis resolve without complication.

 

 

 

Presentation

History

Orchitis is characterized by testicular pain and swelling. The course is variable and ranges from mild discomfort to severe pain.

Associated systemic symptoms include the following:

  • Fatigue

  • Malaise

  • Myalgias

  • Fever and chills

  • Nausea

  • Headache

Mumps orchitis follows the development of parotitis by 4-7 days. Obtain a sexual history, when appropriate.

The clinical manifestations of mumps orchitis in 62 postpubertal vaccinated patients included mean incubation period 5.39 days (range, 0 to 23 days), a febrile duration of 1.8 days (range, 0.5 to 3 days), and a mean duration of orchitis of 4.96 days (range, 0 to 17 days). Sonography revealed unilateral orchitis in 58 patients (93.6%) and bilateral orchitis in 6 (6.4%). The mean age of the 62 patients was 17.56 years (range, 15 to 29 years).[9]

Physical

Testicular examination reveals the following:

  • Testicular enlargement

  • Induration of the testis

  • Tenderness

  • Erythematous scrotal skin

  • Edematous scrotal skin

  • Enlarged epididymis associated with epididymo-orchitis

On rectal examination, there is a soft boggy prostate (prostatitis). often associated with epididymo-orchitis. Mumps orchitis presents unilaterally in 70% of cases. In 30% of cases, contralateral testicular involvement follows by 1-9 days. Other findings include parotitis and fever.

Causes

Most commonly, mumps causes isolated orchitis. The onset of scrotal pain and edema is acute.

Because mumps orchitis is responsible for most cases of isolated orchitis, diagnosis in the ED usually is based on a reported history of a recent mumps infection or parotitis with a presentation of testicular edema.

Other rare viral etiologies include coxsackievirus, infectious mononucleosis, varicella, and echovirus. Some case reports have described mumps orchitis following immunization with the mumps, measles, and rubella (MMR) vaccine.

Bacterial causes usually spread from an associated epididymitis in sexually active men or men with BPH; bacteria include Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus and Streptococcus species. Bacterial orchitis rarely occurs without an associated epididymitis.

Immunocompromised patients have been reported to have orchitis with the following etiologic agents: Mycobacterium avium complex, Cryptococcus neoformans, Toxoplasma gondii, Haemophilus parainfluenzae, and Candida albicans.

Complications

Up to 60% of affected testes demonstrate some degree of testicular atrophy. Impaired fertility is reported at a rate of 7-13%. Sterility is rare in cases of unilateral orchitis. An associated hydrocele or pyocele may require surgical drainage to relieve pressure from the tunica. In one study of 7 patients who were followed after mumps orchitis (4 unilateral, 3 bilateral), in the unilateral orchitis group, 1 patient had an atrophic testis, 3 had severe oligozoospermia, and 1 had mild oligozoospermia. In the bilateral orchitis group, none had atrophic testes, and findings of semen analysis revealed azoospermia in 1 and severe oligozoospermia in 2 patients. Findings of semen analysis in most patients improved gradually.[17]

 

DDx

 

Workup

Laboratory Studies

Laboratory tests are often not helpful in making the diagnosis of orchitis in the ED. Diagnosing mumps orchitis can be comfortably made based on history and physical examination alone. Diagnosing mumps orchitis can be confirmed with serum immunofluorescence antibody testing.

In sexually active males, urethral cultures and gram stain should be obtained for Chlamydia trachomatis and N gonorrhoeae. Urinalysis and urine culture should also be obtained.

Obtaining a C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) may also be helpful, because elevations of these are more suggestive of inflammation associated with epididymo-orchitis.[18, 19]

Imaging Studies

Color Doppler ultrasonography has become the imaging test of choice for the evaluation of acute testicular pain.[1, 20, 21]

Because orchitis often presents as acute edema and pain of the testicle, ruling out testicular torsion is critical. A finding of a normal-sized testicle with decreased flow is suggestive of torsion, whereas a finding of an enlarged epididymis with thickening and increased flow is more suggestive of epididymitis/orchitis.

Often, the history and physical examination are enough to make the diagnosis; however, as an adjunct, ultrasonography is highly sensitive for ruling out testicular torsion and for demonstrating inflammation of the testis or the epididymis.[2, 22]

Procedures

If torsion is likely or if several hours have passed before the patient arrives in the ED, operative exploration is indicated.

Orchitis complicated by a reactive hydrocele or pyocele may require surgical drainage to reduce the pressure in the tunica.

 

Treatment

Emergency Department Care

Supportive treatment includes the following:

  • Bed rest

  • Hot or cold packs for analgesia

  • Scrotal elevation

Most importantly, the physician must rule out testicular torsion.

Second, the physician should consider epididymo-orchitis and, if highly suspected, treat appropriately. This usually involves starting empiric antibiotic therapy.

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.

Medical Care

Symptoms of isolated orchitis usually resolve spontaneously in approximately 3-10 days, whereas epididymitis will usually resolve in a similar time frame after initiation of antibiotic treatment.

Supportive therapy includes the following:

  • Bed rest

  • Scrotal support

  • Analgesics

  • 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

Patients with a suspected sexually transmitted disease should be referred to their private physician or local health department for HIV testing.

Treatment can usually be performed as an outpatient with close follow-up. Indications for admission include the following:

  • Inability to take oral antibiotics

  • Suspicion of abscess formation

  • Failure of previous outpatient therapy

  • Signs of sepsis

Prevention

Pubertal and postpubertal males who have not received mumps vaccination are more susceptible to the virus and have a high risk of mumps orchitis.[11]

Mumps outbreaks have resulted in substantial increases in cases of orchitis. The mumps outbreak in England in 2004-2005 resulted in an increase in orchitis cases of up to 2 to 2.5 times in some populations (those born in the 1970s and 1980s). In comparison, during the years of low mumps incidence following introduction of the MMR vaccine, mumps-related orchitis was significantly reduced in those who did come down with the disease.[4, 23]

In the Czech Republic, 2-dose vaccinations against mumps showed a significant preventive effect agains the mumps complications of orchitis, meningitis, and encephalitis. However, complications increased with the time interval after vaccination.[24]

 

Medication

Medication Summary

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[3] and either doxycycline[3] 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 trimethoprim-sulfamethoxazole. Other appropriate medications include analgesics or antiemetics, as needed.

Antibiotics

Class Summary

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.

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.

Azithromycin (Zithromax)

Treats mild-to-moderate infections caused by susceptible strains of microorganisms.

Indicated for chlamydia and gonorrheal infections of the genital tract.

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Commonly used in patients >35 y with orchitis.

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.

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.

 

Questions & Answers