Should a patient with scrotal cellulitis and epididymo-orchitis (inflammation of the epididymis and testis) consult a urologist?

Should a Patient with Scrotal Cellulitis and Epididymo-Orchitis Consult Urology?

Yes, urology consultation is indicated for scrotal cellulitis with epididymo-orchitis if the patient fails to improve within 3 days of appropriate antibiotic therapy, has persistent swelling after treatment completion, develops complications, or requires surgical evaluation for underlying structural abnormalities. 1, 2

Initial Management in Primary Care

Most uncomplicated cases of epididymo-orchitis can be managed in primary care without immediate urology referral. 1, 3

Age-Based Antibiotic Selection

For men under 35 years:

• Administer ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover sexually transmitted pathogens (Chlamydia trachomatis and Neisseria gonorrhoeae). 1, 3
• These patients typically have sexually transmitted infections as the underlying cause. 4

For men over 35 years:

• Prescribe levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days to target enteric Gram-negative organisms like E. coli. 1, 3
• Alternative therapy includes ciprofloxacin 500 mg orally twice daily for 10 days, though rising fluoroquinolone resistance is a concern. 1, 5

Supportive Care

• Bed rest with scrotal elevation (using rolled towel or supportive underwear) until fever and swelling resolve. 1, 2, 3
• Analgesics for pain control during the acute phase. 1, 2, 3

Mandatory Urology Referral Criteria

Immediate Surgical Consultation Required

Testicular torsion must be ruled out emergently if pain onset is sudden and severe, as testicular viability is compromised within 4-6 hours. 2, 6 This is a surgical emergency requiring immediate specialist evaluation, not a routine urology referral. 7

Urgent Urology Referral (Within 3 Days)

• No clinical improvement within 3 days of initiating appropriate antibiotic therapy requires reevaluation of both diagnosis and treatment. 1, 2, 3
• Severe pain or systemic illness (high fever, sepsis) necessitates hospital admission for IV antibiotics and specialist evaluation. 6

Non-Urgent Urology Referral

Persistent swelling or palpable masses after completing antimicrobial therapy require comprehensive urological evaluation to exclude tumor, abscess, testicular infarction, tuberculosis, or fungal epididymitis. 1, 2

Men over 50 years should receive formal urological follow-up to investigate underlying structural abnormalities such as benign prostatic hyperplasia, urethral stricture, or bladder outlet obstruction that predispose to recurrent infections. 5, 8, 6

Scrotal Cellulitis Considerations

The addition of scrotal cellulitis (skin and soft tissue infection) to epididymo-orchitis may indicate more severe infection or Fournier gangrene risk. 7 While not explicitly addressed in epididymitis guidelines, any concern for necrotizing fasciitis or Fournier gangrene requires immediate surgical consultation, as this is a life-threatening emergency. 7

Common Pitfalls to Avoid

• Don't assume improvement means cure: Complete the full 10-day antibiotic course even if symptoms resolve earlier, as premature discontinuation leads to treatment failure and chronic complications. 1
• Don't miss testicular torsion: The clinical presentations overlap significantly, and torsion requires surgery within 4-6 hours to prevent testicular loss. 7, 2
• Don't neglect partner management: All sexual partners from the past 60 days require evaluation and treatment for sexually transmitted epididymo-orchitis. 1, 2, 3
• Don't resume sexual activity prematurely: Patients must abstain until both they and their partners complete treatment and are asymptomatic. 1, 2, 3

Diagnostic Testing Before Referral

• Ultrasound with Doppler is the initial imaging modality to confirm diagnosis and exclude torsion, abscess, or tumor. 7
• Urine culture and Gram stain for men over 35 years to identify enteric pathogens. 2, 4
• Nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia in men under 35 years or those with urethritis. 2, 4
• HIV testing and syphilis screening are recommended as sexually transmitted epididymitis indicates risk for other infections. 1, 2

Special Populations

HIV-positive patients with uncomplicated epididymo-orchitis receive the same treatment as HIV-negative patients, though immunosuppressed individuals may have fungal or mycobacterial causes requiring different approaches and earlier specialist involvement. 1, 2, 3