Can Hand, Foot, and Mouth Disease (HFMD) cause epididymoorchitis?

Hand, Foot, and Mouth Disease Can Cause Epididymoorchitis

Yes, Hand, Foot, and Mouth Disease (HFMD) can cause epididymoorchitis as a rare complication, as documented in case reports where coxsackievirus A6 has been isolated from epididymal fluid. 1, 2

Pathophysiology and Evidence

Hand, Foot, and Mouth Disease is primarily a childhood febrile illness characterized by oral lesions and papulovesicular lesions on the hands and feet. While it typically presents with these characteristic features, the virus can occasionally affect other organs, including the male reproductive system:

• Case evidence shows that HFMD can lead to viral epididymo-orchitis, particularly in young males with a recent history of HFMD 1
• Coxsackievirus A6 (CV-A6), a causative agent of HFMD, has been specifically isolated from epididymal fluid in patients with epididymitis 2
• The infection pathway appears to be different from the typical bacterial epididymitis, which usually occurs through retrograde ascent of pathogens 3

Diagnostic Approach for Suspected Cases

When epididymoorchitis is suspected in a patient with recent or current HFMD:

• Ultrasound with Doppler is essential to confirm the diagnosis and rule out other conditions such as testicular torsion 4
• Typical ultrasound findings include a hypoechoic mass-like area in the affected testis 1
• Key differential diagnosis is testicular torsion, which requires immediate surgical intervention:
  • Epididymo-orchitis: gradual onset, positive Prehn sign (pain relief with elevation), normal testicular position, increased blood flow on Doppler
  • Testicular torsion: sudden onset, negative Prehn sign, high-riding testis, decreased/absent blood flow on Doppler 4

Management Considerations

Unlike bacterial epididymitis, viral epididymoorchitis associated with HFMD may not require specific treatment:

• In documented cases, conservative management without antimicrobial therapy has been successful 1
• Follow-up ultrasound examinations have shown reduction in lesion size over time (approximately 3 months) 1
• Supportive measures may include:
  • Bed rest
  • Scrotal elevation
  • Analgesics for pain management
  • Adequate fluid intake 4

Important Clinical Considerations

• HFMD-associated epididymoorchitis can mimic testicular torsion, potentially leading to unnecessary surgical intervention 2
• Clinicians should consider viral etiology in young males presenting with testicular pain who have a recent history of HFMD or characteristic rashes 1
• Unlike bacterial epididymitis, which is commonly caused by sexually transmitted infections in young adults or enteric bacteria in older men, HFMD-associated epididymoorchitis has a viral etiology 4, 3

Risk Factors for Severe HFMD

While epididymoorchitis is a rare complication, certain factors increase the risk of severe HFMD in general:

• EV71 infection (as opposed to other enterovirus types)
• Fever lasting more than 3 days
• Neurological symptoms (limb trembling, pathologic reflexes, lethargy, convulsions)
• Vomiting
• Dyspnea 5

Recognizing these risk factors may help identify patients at higher risk for complications, including potential genitourinary involvement.