Approach Considerations

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 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.^{[22, 23]}

Imaging Studies

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]}

Treatment & Management

Azmat CE, Vaitla P. Orchitis. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. 2004 Mar. 42(2):349-63. [QxMD MEDLINE Link].
Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009 Apr 1. 79(7):583-7. [QxMD MEDLINE Link].
Lane TM, Hines J. The management of mumps orchitis. BJU Int. 2006 Jan. 97(1):1-2. [QxMD MEDLINE Link].
Masarani M, Wazait H, Dinneen M. Mumps orchitis. J R Soc Med. 2006 Nov. 99(11):573-5. [QxMD MEDLINE Link]. [Full Text].
Tae BS, Ham BK, Kim JH, Park JY, Bae JH. Clinical features of mumps orchitis in vaccinated postpubertal males: a single-center series of 62 patients. Korean J Urol. 2012 Dec. 53 (12):865-9. [QxMD MEDLINE Link].
Davis NF, McGuire BB, Mahon JA, et al. The increasing incidence of mumps orchitis: a comprehensive review. BJU International. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2009.09148.x/full. April 2010; Accessed: August 26, 2016.
Takeshima T, Yumura Y, Iwasaki A, Noguchi K. [Clinical Review of Hypospermatogenesis in Patients with a Previous Episode of Mumps Orchitis]. Hinyokika Kiyo. 2015 Jun. 61 (6):227-33. [QxMD MEDLINE Link].
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. 2007 Nov. 89(8):799-803. [QxMD MEDLINE Link]. [Full Text].
Ternavasio-de la Vega HG, Boronat M, Ojeda A, García-Delgado Y, Angel-Moreno A, Carranza-Rodríguez C, et al. Mumps orchitis in the post-vaccine era (1967-2009): a single-center series of 67 patients and review of clinical outcome and trends. Medicine (Baltimore). 2010 Mar. 89(2):96-116. [QxMD MEDLINE Link].
Yamashita S, Umemoto H, Kohjimoto Y, Hara I. Xanthogranulomatous orchitis after blunt testicular trauma mimicking a testicular tumor: A case report and comparison with published cases. Urol J. 2017 May 23. 14 (3):3094-3096. [QxMD MEDLINE Link].
Gazibera B, Gojak R, Drnda A, et al. Spermiogram part of population with the manifest orchitis during an ongoing epidemic of mumps. Med Arh. 2012. 66(3 Suppl 1):27-9. [QxMD MEDLINE Link].
Corbett HJ, Simpson ET. Management of the acute scrotum in children. ANZ J Surg. 2002 Mar. 72(3):226-8. [QxMD MEDLINE Link].
Yung CF, Ramsay M. Estimating true hospital morbidity of complications associated with mumps outbreak, England, 2004/05. Euro Surveill. 2016 Aug 18. 21 (33):[QxMD MEDLINE Link].
Orlíková H, Malý M, Lexová P, Šebestová H, Limberková R, Jurzykowská L, et al. Protective effect of vaccination against mumps complications, Czech Republic, 2007-2012. BMC Public Health. 2016 Apr 1. 16:293. [QxMD MEDLINE Link].
Yagil Y, Naroditsky I, Milhem J, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. 2010 Jan. 29(1):11-21. [QxMD MEDLINE Link].
Artul S, Abu Rahmah Y, Abu Shkara H, Yamini A. Inferno: colour Doppler ultrasound sign of orchitis. BMJ Case Rep. 2014 Apr 1. 2014:[QxMD MEDLINE Link]. [Full Text].
Ngoo A, Rodriguez-Acevedo O, Carroll D, Stalewski H, Mariyappa Rathnamma B. Salmonella epididymo-orchitis presenting as acute scrotum in a 2-week-old infant. J Paediatr Child Health. 2018 Nov 8. [QxMD MEDLINE Link].
[Guideline] Street EJ, Justice ED, Kopa Z, Portman MD, Ross JD, Skerlev M, et al. The 2016 European guideline on the management of epididymo-orchitis. Int J STD AIDS. 2017 Jul. 28 (8):744-749. [QxMD MEDLINE Link]. [Full Text].
Wu H, Wang F, Tang D, Han D. Mumps Orchitis: Clinical Aspects and Mechanisms. Front Immunol. 2021. 12:582946. [QxMD MEDLINE Link].
[Guideline] Expert Panel on Urologic Imaging: Hartman MS, Leyendecker JR, Friedman B, et al. ACR Appropriateness Criteria ® acute onset of scrotal pain--without trauma, without antecedent mass. American College of Radiology. Available at https://acsearch.acr.org/docs/69363/Narrative/. 2014; Accessed: December 8, 2018.
Silva CA, Cocuzza M, Carvalho JF, Bonfá E. Diagnosis and classification of autoimmune orchitis. Autoimmun Rev. 2014 Apr-May. 13(4-5):431-4. [QxMD MEDLINE Link].
Akaboshi I. Elevation of Serum Levels of High-Sensitivity Procalcitonin, C-reactive Protein, and Amyloid A in a Prepubertal Child with Mumps Orchitis. Clin Lab. 2015. 61 (11):1795-8. [QxMD MEDLINE Link].
Suciu M, Serban O, Iacob G, Lucan C, Badea R. Severe Acute Epididymo-Orchitis Complicated with Abscess and Testicular Necrosis - Case Report. Ultrasound Int Open. 2017 Feb. 3 (1):E45-E47. [QxMD MEDLINE Link]. [Full Text].
Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. 2001 Jan. 8(1):90-3. [QxMD MEDLINE Link].
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. 2006 Aug. 41(8):1377-80. [QxMD MEDLINE Link].
Tomich A, Grubish L, Young S, Franklin J. Immunocompetent, Immunized Male With Mumps, Complicated by Orchitis and Meningitis. Mil Med. 2015 Oct. 180 (10):e1121-2. [QxMD MEDLINE Link].
Masarani M, Wazait H, Dinneen M. Mumps orchitis. Journal of the Royal Society of Medicine. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633545/. November 2006; Accessed: August 26, 2016.
Janssen KM, Willis CJ, Anderson M, Gelnett MS, Wickersham EL, Brand TC. Filariasis Orchitis-Differential for Acute Scrotum Pathology. Urol Case Rep. 2017 Jul. 13:117-119. [QxMD MEDLINE Link].
Chu CY, Chen WY, Yeh SD, Yeh HM, Fang CL. Syphilitic orchitis mimicking a testicular tumor in a clinically occult HIV-infected young man: a case report with emphasis on a challenging pathological diagnosis. Diagn Pathol. 2016 Jan 14. 11:4. [QxMD MEDLINE Link].
Manson AL. Mumps orchitis. Urology. 1990 Oct. 36(4):355-8. [QxMD MEDLINE Link].
Gift TL, Owens CJ. The direct medical cost of epididymitis and orchitis: evidence from a study of insurance claims. Sex Transm Dis. 2006 Oct. 33(10 Suppl):S84-8. [QxMD MEDLINE Link].
Pal G. The effects of pegylated interferon--alpha2B on mumps orchitis. J Indian Med Assoc. 2013 Sep. 111(9):612-4, 617. [QxMD MEDLINE Link].
Rosenstein D, McAninch JW. Urologic emergencies. Med Clin North Am. 2004 Mar. 88(2):495-518. [QxMD MEDLINE Link].
Shafik A, El-Sibal O, Shafik I. Electro-orchidogram: a non-invasive diagnostic tool in testicular pathologies. Med Sci Monit. 2006 Aug. 12(8):MT51-5. [QxMD MEDLINE Link].
Tiemstra JD, Kapoor S. Evaluation of scrotal masses. Am Fam Physician. 2008 Nov 15. 78(10):1165-70. [QxMD MEDLINE Link].
Walker NA, Challacombe B. Managing epididymo-orchitis in general practice. Practitioner. 2013 Apr. 257(1760):21-5, 2-3. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Nataisia Terry, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Nataisia Terry, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Walter W Valesky, Jr, MD Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Additional Contributors

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Acknowledgements

Mark B Mycyk, MD Associate Professor, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine

Mark B Mycyk, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.