What are the potential complications of epididymoorchitis in a young to middle-aged man with a history of sexually transmitted infections or urinary tract infections?

Complications of Epididymoorchitis

The most critical complications of epididymoorchitis include testicular abscess, testicular infarction, chronic pain syndromes, infertility from testicular atrophy, and the potential for misdiagnosis of testicular cancer or torsion, with persistent symptoms after treatment requiring comprehensive evaluation for tumor, abscess, or infarction. 1, 2

Acute Life-Threatening Complications

Testicular Torsion (Misdiagnosis Risk)

• Testicular torsion represents a surgical emergency that must be ruled out in all cases of acute testicular pain, as testicular viability becomes compromised within 4-6 hours. 2, 3
• Emergency testing for torsion is indicated when pain onset is sudden and severe, particularly in adolescents where torsion is more frequent. 2, 4
• This is the most important differential diagnosis, especially in younger men, and requires immediate surgical consultation if suspected. 2, 3

Testicular Abscess

• Palpable masses or persistent swelling after treatment completion may indicate abscess formation and require immediate surgical consultation. 1
• Abscess is part of the differential diagnosis for persistent symptoms after completing antimicrobial therapy. 2

Chronic Complications

Testicular Infarction

• Infarction is a recognized complication that presents as persistent swelling and tenderness after completing antimicrobial therapy. 2, 4
• This requires comprehensive evaluation and surgical consultation for palpable masses or persistent swelling. 1

Chronic Pain and Inflammation

• Chronic epididymoorchitis is defined as symptoms persisting for more than three months and typically presents with ongoing testicular pain and swelling. 3
• Persistent swelling and tenderness after completing antimicrobial therapy necessitates comprehensive evaluation. 2

Testicular Atrophy and Infertility

• While not explicitly detailed in the guidelines, testicular atrophy can result from severe or inadequately treated epididymoorchitis, potentially leading to fertility issues.

Infectious Complications

Treatment Failure and Recurrence

• Reevaluation is necessary if no improvement occurs within 3 days of treatment initiation, as this may indicate treatment failure requiring diagnosis and treatment change. 1, 2, 4
• Stopping antibiotics early can lead to treatment failure and complications, emphasizing the need to complete the entire 10-day course even if symptoms improve. 1

Spread to Sexual Partners

• All sexual partners from the past 60 days must be evaluated and treated if the infection is caused by gonorrhea or chlamydia, even if asymptomatic. 1, 2, 4
• Resuming sexual activity prematurely spreads infection to partners and can worsen the patient's condition. 1

Diagnostic Complications (Mimics)

Testicular Cancer

• Testicular cancer is part of the differential diagnosis for persistent symptoms after treatment, requiring comprehensive evaluation. 2, 4
• This highlights the importance of follow-up for persistent masses or swelling. 1

Tuberculosis and Fungal Epididymitis

• Tuberculosis and fungal epididymitis are considerations in the differential diagnosis, particularly in immunosuppressed patients. 2, 4
• Fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients, including those with HIV. 2, 4

Prevention of Complications

Early Recognition and Treatment

• Complete the entire 10-day antibiotic course to prevent chronic complications, as stopping early leads to treatment failure. 1
• Return within 3 days if pain, swelling, or fever don't improve for reevaluation. 1, 2

Proper Antibiotic Selection

• For men under 35: ceftriaxone 250 mg IM single dose plus doxycycline 100 mg orally twice daily for 10 days covers sexually transmitted pathogens. 2, 4, 5
• For men over 35: ofloxacin 300 mg orally twice daily for 10 days or levofloxacin 500 mg orally once daily for 10 days targets enteric organisms. 1, 2, 4

Supportive Care

• Bed rest with scrotal elevation using a rolled towel or supportive underwear until fever and swelling subside reduces inflammation and complications. 1, 2, 4
• Analgesics for pain control during the acute phase improve patient comfort and compliance. 1, 2, 4

Common Pitfalls Leading to Complications

• Don't assume cure when pain improves—the infection requires the full antibiotic course to prevent chronic complications. 1
• Patients who are in severe pain or systemically unwell should be referred for IV antibiotics and hydration to prevent progression. 4, 3
• Hospitalization should be considered when severe pain suggests other diagnoses or when patients may not comply with the antimicrobial regimen. 4