Should I treat for orchitis with bilateral swollen testes, no pain, normal white blood cell (WBC) count, and no systemic symptoms of infection?

Management of Bilateral Swollen Testes Without Signs of Infection

In the absence of pain, normal WBC count, and no systemic symptoms of infection, treatment for orchitis is not recommended as this presentation does not support an infectious etiology.

Diagnostic Considerations

When evaluating bilateral testicular swelling without pain or signs of infection, the following diagnostic approach is essential:

• Rule out testicular malignancy: A solid mass in the testis should be managed as a malignant neoplasm until proven otherwise 1. Bilateral testicular fullness without pain warrants careful evaluation.

• Imaging evaluation: Scrotal ultrasound with Doppler should be obtained to assess for:

  • Presence of solid masses
  • Testicular microlithiasis
  • Vascular flow patterns
  • Extratesticular abnormalities 1, 2

• Laboratory assessment:

  • Serum tumor markers (AFP, β-hCG, LDH) should be measured prior to any treatment 1, 2
  • Normal WBC count already suggests non-infectious etiology

Differential Diagnosis

The bilateral testicular swelling without pain and inflammatory markers suggests several non-infectious etiologies:

1. Testicular microlithiasis: Isolated testicular microlithiasis without other abnormalities requires no treatment, only patient education on testicular self-examination 2

2. Early testicular neoplasm: May present with painless testicular enlargement and requires urgent urological referral 1

3. Non-infectious orchitis: Could represent autoimmune orchitis, which is characterized by testicular inflammation without infectious etiology 3

4. Varicocele: May present with testicular fullness, especially when bilateral

Management Approach

1. Do not initiate empiric antibiotics:

   • The absence of pain, normal WBC count, and lack of systemic symptoms strongly argue against infectious orchitis
   • Empiric antibiotics are only indicated for orchitis when signs of infection are present 1, 4

2. Perform a complete urologic evaluation:

   • Scrotal ultrasound to assess for masses, microlithiasis, or other structural abnormalities
   • Serum tumor markers to rule out testicular malignancy 1

3. Consider specialist referral:

   • Urology consultation is appropriate for further evaluation of bilateral testicular swelling
   • If ultrasound reveals suspicious findings, urgent referral is warranted 2

4. Follow-up recommendations:

   • If initial evaluation is negative but swelling persists, repeat imaging in 6-8 weeks 1
   • Patient education on testicular self-examination

Important Caveats

• Bilateral testicular swelling without pain is atypical for infectious orchitis, which typically presents with acute pain, fever, and elevated WBC count 5

• Avoid the common pitfall of treating non-infectious conditions with antibiotics, as this contributes to antimicrobial resistance without clinical benefit

• If testicular malignancy is suspected based on ultrasound findings, do not delay urological referral even in the absence of pain or elevated tumor markers 1

• Consider autoimmune orchitis in the differential diagnosis, especially if the patient has a history of autoimmune disease 3