Orchitis

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. Salmonella is a rare cause of epididymo-orchitis that disproportionately affects neonates.[18] 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.

Orchitis may have a noninfectious etiology. It occurs in 12-19% of men with Behcet disease, usually with more severe disease. Amiodarone-induced epididymo-orchitis has also been reported.[19]

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.

Epididymitis also occurs in most cases of mumps orchitis and results in epididymo-orchitis.[20]

In a study by Tae et al, the clinical manifestations of mumps orchitis in 62 postpubertal vaccinated patients included a mean incubation period of 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).[6]

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

Epididymo-orchitis is a clinical diagnosis based on symptoms and signs. The history, eliciting genitourinary symptoms and the risk of exually transmitted infections (including anal intercourse), alongside examination findings and preliminary investigations, will suggest the most likely etiology and guide use of empiric antibiotics. Historically, sexually transmitted infections have been identified as the predominant cause for epididymitis in persons younger than 35 years, and enteric pathogens the primary cause in persons older than 35 years. Evidence to support this approach is limited; and age and sexual history are not sufficient for guiding antibiotic therapy alone.[19]

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.[22, 23]

Color Doppler ultrasonography has become the imaging test of choice for the evaluation of acute testicular pain.[2, 16, 17]

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.[24]

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.[25, 26]

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.

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.

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.

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

The International Union against Sexually Transmitted Infections (IUSTI) has released guidelines on the management of epidiymo-orchitis that includes the following key recommendations[19] :

• Information, explanation and advice should be given to the patient, including an explanation of the causes of epididymo-orchitis (both sexually transmitted and non-sexually transmitted), the short-term course of the infection, and the long-term implications for patients and partners, including partner notification if a sexually transmitted cause is identified or suspected.
• Treatment includes analgesia, rest, and scrotal support.
• Sexual abstinence recommended for those with a suspected sexually transmitted etiology until treatment is completed by both patient and partner and symptoms have resolved.
• Empiric antibiotics should be given according to the likelihood of a sexually transmitted infection or uropathogen.

The recommended antibiotics for sexually transmitted epidiymo-orchitis include ceftriaxone (first line) and ofloxacin (second line).

The recommended antibioitic for epidiymo-orchitis secondary to enteric organisms is ofloxacin. 

When Mycoplasma genitalium testing has been performed and the organism identified, treatment should be guided to include an appropriate antibiotic (eg, moxifloxacin).

When Neisseria gonorrhoeae is considered unlikely, omitting ceftriaxone or using ofloxacin could be considered. Ofloxacin is not a first-line treatment for N gonorrhoeae because of increasing bacterial resistance to quinolones. In patients in whom N gonorrhoeae is considered likely, azithromycin should be added to ceftriaxone and doxycycline to provide optimal antibiotic coverage.[19]

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.

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.