What is the treatment for orchitis?

Treatment of Orchitis

The treatment of orchitis depends on its etiology, with antibiotics being the cornerstone therapy for bacterial causes, typically using ceftriaxone plus doxycycline for sexually transmitted infections or fluoroquinolones for enteric bacteria, along with supportive measures including rest, scrotal elevation, and pain management. 1

Diagnosis and Etiology

Before initiating treatment, it's crucial to establish the correct diagnosis and identify the underlying cause:

• Clinical Presentation: Orchitis typically presents with unilateral testicular pain, tenderness, and swelling, often with gradual onset. It frequently occurs with epididymitis (epididymo-orchitis) 1

• Diagnostic Workup:

  • Urethral swab or first-void urine for STI testing
  • Urinalysis and urine culture
  • Scrotal ultrasound with Doppler to rule out testicular torsion 1

• Etiology:

  • In men <35 years: Primarily sexually transmitted infections (Chlamydia trachomatis and Neisseria gonorrhoeae) 2, 1
  • In men >35 years: Primarily enteric bacteria, especially E. coli 2, 1
  • Mumps virus is a common viral cause of isolated orchitis 2

Treatment Approach

1. Antimicrobial Therapy

For epididymo-orchitis likely caused by STIs (men <35 years):

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 2, 3

For epididymo-orchitis likely caused by enteric organisms (men >35 years or those allergic to cephalosporins/tetracyclines):

• Ofloxacin 300 mg orally twice daily for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days 2

For fungal or mycobacterial orchitis (more common in immunocompromised patients):

• Antifungal or anti-tuberculosis drugs based on culture results 2

2. Supportive Measures

• Bed rest until fever and local inflammation subside
• Scrotal elevation to improve drainage and reduce swelling
• Analgesics for pain management 2, 1
• Non-steroidal anti-inflammatory drugs for pain and inflammation 2

3. Management of Complications

For granulomatous prostatitis:

• If symptomatic: isoniazid and rifampicin orally for three months, plus quinolone antibiotics and corticosteroids 2

For abscess formation:

• Surgical drainage may be necessary
• Consider orchiectomy in severe cases unresponsive to treatment 2

Monitoring and Follow-up

• Clinical improvement should occur within 3 days of starting treatment
• If no improvement within 3 days, reevaluate diagnosis and therapy 2, 1
• Persistent swelling and tenderness after completing antibiotics requires comprehensive evaluation for other conditions such as tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal infection 2, 1

Special Considerations

HIV-Infected Patients

• Should receive the same treatment regimen as HIV-negative patients
• Higher suspicion for fungal and mycobacterial causes 2

Partner Management

• For STI-related orchitis, 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

Warning Signs Requiring Immediate Attention

• Sudden onset of severe unilateral scrotal pain
• Nausea/vomiting
• High-riding testicle
• Absent cremasteric reflex

These signs suggest testicular torsion, which is a surgical emergency requiring immediate consultation 1

Common Pitfalls

1. Misdiagnosing testicular torsion as orchitis - torsion requires immediate surgical intervention
2. Not testing for both bacterial and viral causes
3. Failing to reevaluate patients who don't respond to initial therapy
4. Not considering non-infectious causes of testicular pain and swelling
5. Inadequate partner treatment in cases of STI-related orchitis

Remember that prompt and appropriate treatment is essential to prevent complications such as abscess formation, testicular ischemia, infertility, and chronic scrotal pain 1.