What is the initial management for a 17-year-old male with orchitis?

Initial Management of Orchitis in a 17-Year-Old Male

In a 17-year-old male with orchitis, immediately rule out testicular torsion first with urgent Doppler ultrasound and surgical consultation if high suspicion exists, then initiate empiric antibiotic therapy targeting Chlamydia trachomatis and Neisseria gonorrhoeae with ceftriaxone 250 mg IM once plus doxycycline 100 mg orally twice daily for 10 days. 1, 2, 3

Critical First Step: Exclude Testicular Torsion

• Testicular torsion is a surgical emergency that must be ruled out immediately in any adolescent presenting with acute scrotal pain, as testicular viability is compromised if not treated within 6-8 hours of symptom onset 4

• Torsion occurs more frequently in adolescents than adults, with a peak incidence in postpubertal boys 1, 4

• Key distinguishing features favoring torsion over orchitis include:

  • Abrupt onset of severe pain (versus gradual onset in orchitis) 4, 3
  • Absence of urinary symptoms 3
  • Negative urinalysis (though normal urinalysis does not exclude torsion) 4
  • Absent cremasteric reflex 3

• If clinical suspicion for torsion is high, proceed directly to surgical exploration without delay for imaging 4

• For intermediate suspicion, obtain urgent Duplex Doppler ultrasound showing decreased/absent testicular blood flow in torsion versus increased flow in orchitis 4

Empiric Antibiotic Therapy

Once torsion is excluded, immediately initiate empiric antibiotics before culture results return 1:

For Sexually Transmitted Pathogens (Primary Concern in 17-Year-Old)

Recommended regimen:

• Ceftriaxone 250 mg intramuscularly as a single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2

This combination targets C. trachomatis and N. gonorrhoeae, which are the most common pathogens in males aged 14-35 years 3, 5

Alternative Regimen

• If cephalosporin allergy or enteric organisms suspected: Levofloxacin 500 mg orally once daily for 10 days 1

Diagnostic Workup

Obtain the following tests before or concurrent with antibiotic initiation:

• Urethral Gram stain (if urethral discharge present) to identify >5 polymorphonuclear leukocytes per oil immersion field, indicating urethritis 1
• Nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 1, 5
• Urinalysis and urine culture on first-void uncentrifuged urine 1
• Syphilis serology and HIV testing should be offered 1

Important caveat: Only 50% of men diagnosed with epididymitis/orchitis in emergency settings actually receive STI testing, yet 13.8% test positive—emphasizing the importance of universal testing in this age group 5

Supportive Care Measures

Adjunctive therapy is essential and should be initiated immediately:

• Bed rest until fever and inflammation subside 1
• Scrotal elevation to reduce swelling and pain 1
• Analgesics (NSAIDs preferred for anti-inflammatory effect) 1

Special Diagnostic Considerations in Adolescents

Mumps Orchitis

• Ask specifically about parotid gland swelling in the preceding 10 days, as 82-90% of mumps orchitis cases have preceding parotitis 6
• However, 10-18% of mumps complications occur without parotitis, making diagnosis challenging 6
• Mumps orchitis occurs in up to 38% of postpubertal males with mumps infection 6
• Even vaccinated adolescents can develop mumps due to waning immunity 6

Sexual Assault History

• Confidentially screen for sexual assault, as adolescents may not volunteer this information due to self-blame or humiliation 1
• If assault occurred, prophylactic STI treatment is indicated even without symptoms: ceftriaxone 125 mg IM, metronidazole 2 g orally once, and azithromycin 1 g orally once 1

Follow-Up Protocol

Mandatory reassessment within 3 days:

• If no improvement within 72 hours, reevaluate both diagnosis and therapy 1
• Consider alternative diagnoses including testicular tumor, abscess, tuberculosis, or fungal infection 1

Partner notification and treatment:

• All sexual partners within 60 days preceding symptom onset must be evaluated and treated 1
• Patient should abstain from sexual intercourse until both he and partners complete therapy and are asymptomatic 1

Repeat STI testing:

• Syphilis and HIV testing should be repeated at 6 weeks, 3 months, and 6 months if initial results negative 1

Common Pitfalls to Avoid

• Never delay torsion evaluation based on gradual symptom onset alone—atypical presentations occur 4
• Do not rely on the Prehn sign (pain relief with testicular elevation) to differentiate orchitis from torsion, as it has poor sensitivity and specificity 7
• Do not assume negative urinalysis excludes bacterial infection—20% of men with orchitis have positive urine cultures despite normal urinalysis 5
• Do not skip STI testing even if patient denies sexual activity—confidential screening is essential 5
• Persistent swelling after antibiotic completion requires comprehensive evaluation for malignancy, abscess, or chronic infection 1