Epididymoorchitis: Definition, Diagnosis, and Management
Epididymoorchitis is an inflammatory condition affecting both the epididymis and testis, typically caused by infectious agents that reach these structures through retrograde propagation via the vas deferens or hematogenous spread. 1
Etiology and Epidemiology
The causative organisms vary by age group:
Men <35 years: Most commonly caused by sexually transmitted infections (STIs)
Men >35 years: More commonly caused by enteric organisms associated with urinary tract infections
Special cases:
Clinical Presentation
- Unilateral testicular pain and tenderness with gradual onset
- Palpable swelling of the epididymis
- Hydrocele may be present
- Often accompanied by urethritis (which may be asymptomatic)
- Fever and systemic symptoms may occur in severe cases 2, 1
Diagnostic Approach
Physical examination:
- Assess for unilateral testicular pain, tenderness, and swelling
- Check for presence of hydrocele
- Evaluate for Prehn sign (pain relief with testicular elevation) 1
Laboratory testing:
Imaging:
- Doppler ultrasound of the scrotum is the standard imaging modality
- Helps distinguish inflammatory conditions from testicular torsion
- Shows increased blood flow in epididymoorchitis (versus decreased/absent flow in torsion) 1
Differential Diagnosis
Critical to distinguish from testicular torsion, which is a surgical emergency:
| Feature | Epididymoorchitis | Testicular Torsion |
|---|---|---|
| Onset | Gradual | Sudden |
| Pain relief with elevation | Yes (Prehn sign) | No |
| Cremasteric reflex | Present | Absent |
| Testicular position | Normal | High-riding |
| Doppler ultrasound | Increased blood flow | Decreased/absent blood flow |
Other conditions to consider: testicular tumor, abscess, infarction, and tuberculous or fungal epididymitis 2
Treatment
For men <35 years (likely STI-related):
For men >35 years (likely enteric organisms):
- Ofloxacin 300 mg orally twice a day for 10 days
- OR Levofloxacin 500 mg orally once daily for 10 days 2, 1
Supportive measures:
- Bed rest
- Scrotal elevation
- Analgesics until fever and local inflammation subside 2
Hospitalization considerations:
- Severe pain suggesting alternative diagnoses
- Febrile patients
- Concerns about medication non-compliance 2, 1
Follow-Up and Complications
Clinical improvement should occur within 3 days of starting treatment
Failure to improve requires reevaluation of diagnosis and therapy
Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for other conditions 2, 1
Potential complications include:
Management of Sexual Partners
- For STI-related epididymoorchitis, sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
- Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 2, 1
Special Considerations
- HIV-infected patients: Should receive the same treatment regimen as HIV-negative patients, but be aware that fungal and mycobacterial causes are more common 2, 1
- Antibiotic resistance: Rising resistance to fluoroquinolones in E. coli isolates may necessitate alternative antimicrobials with adequate penetration into genital tissues 4
- Surgical intervention: May be necessary if no clinical improvement is observed within 48-72 hours of conservative treatment, particularly in cases with hydrocele, abscess formation, or inability to differentiate between epididymis and testis on examination 3