What is the recommended evaluation and treatment for orchitis in adolescents and sexually active men?

Orchitis: Evaluation and Treatment in Adolescents and Sexually Active Men

Critical First Step: Rule Out Testicular Torsion

In any adolescent or young man presenting with acute testicular pain, testicular torsion must be immediately excluded as it is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss. 1

• Testicular torsion presents with abrupt onset of severe scrotal pain, while epididymo-orchitis has gradual onset over hours to days 1
• Testicular torsion is more common in adolescents with a bimodal peak in neonates and postpubertal boys 1
• A negative Prehn sign (pain NOT relieved with testicular elevation) suggests torsion, while a positive Prehn sign (pain relief with elevation) suggests epididymo-orchitis 2
• If clinical suspicion for torsion is high, proceed immediately to urological consultation and surgical exploration—do not delay for imaging 1
• For intermediate suspicion cases, urgent Duplex Doppler ultrasound should be performed showing decreased/absent blood flow and the "whirlpool sign" in torsion 1

Age-Based Diagnostic Approach

For Sexually Active Men Ages 14-35 Years

The most common pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, and diagnostic testing must include urethral specimens, not just urinalysis. 2

Diagnostic evaluation:

• Obtain urethral Gram stain looking for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 3
• Perform nucleic acid amplification testing (NAAT) on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 2
• Examine first-void uncentrifuged urine for leukocytes (pyuria) 2
• Critical pitfall: Relying solely on urinalysis misses the majority of STI-related cases, as these infections originate from urethral pathogens 2
• Current tests for C. trachomatis are not sufficiently sensitive to exclude infection even when negative 2
• Obtain syphilis serology and offer HIV counseling/testing 3

For Men Over 35 Years

Enteric Gram-negative bacteria, particularly E. coli, are the predominant pathogens, often associated with bladder outlet obstruction or urinary tract abnormalities. 2

Diagnostic evaluation:

• Urinalysis and urine culture with Gram stain for Gram-negative bacteria 2
• Assess for risk factors: benign prostatic hyperplasia, urethral stricture, recent urinary instrumentation, or anatomical abnormalities 2, 4

Clinical Presentation Features

Typical presentation includes:

• Gradual onset of unilateral testicular pain and tenderness over hours to days 2
• Palpable epididymal swelling beginning at the lower pole and progressing upward 2
• Scrotal swelling, erythema, and elevated scrotal temperature 2
• May have urethral discharge, dysuria, or urinary frequency in STI-related cases 2
• Fever can occur in severe cases 2
• Positive Prehn sign (pain relief with scrotal elevation) 2

Warning signs requiring urgent evaluation:

• High fever, rigors, nausea, vomiting suggest possible abscess or Fournier's gangrene 2
• Scrotal skin crepitus, necrosis, or rapidly spreading erythema suggest necrotizing infection 2

Treatment Recommendations

For Sexually Active Men <35 Years (STI-Related)

Treat empirically with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 2, 3

• This regimen covers both N. gonorrhoeae and C. trachomatis 3
• Treatment should be initiated even with negative urinalysis if clinical presentation is consistent 2
• Do NOT use nitrofurantoin or fosfomycin—these have inadequate tissue penetration 2

For Men >35 Years (Enteric Organism-Related)

First-line options:

• Levofloxacin 500 mg orally once daily for 10 days 2, 3
• OR Ofloxacin 300 mg orally twice daily for 10 days 2, 3

For severe disease requiring hospitalization:

• Parenteral aminoglycoside plus cephalosporin, followed by oral fluoroquinolone or trimethoprim-sulfamethoxazole based on culture results 5
• Note: Rising fluoroquinolone resistance in E. coli may necessitate alternative agents based on local resistance patterns 4

Supportive Care (All Patients)

• Bed rest, scrotal elevation, and scrotal supporter to reduce edema 2
• Anti-inflammatory medications for pain control 2
• Analgesics until fever and local inflammation subside 3

Follow-Up and Monitoring

Re-evaluate at 48-72 hours to confirm clinical improvement. 2

• If no improvement after 72 hours of appropriate antibiotics, perform scrotal ultrasonography and consider changing antibiotics based on culture results 2
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for alternative diagnoses including tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 3

Management of Sexual Partners

For STI-related cases:

• Partners from the 60 days preceding symptom onset should be referred for evaluation and treatment 3
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 3

Special Considerations

• HIV-positive patients with uncomplicated epididymo-orchitis receive the same treatment regimen as HIV-negative patients 3
• Fungi and mycobacteria are more likely in immunosuppressed patients 3
• Chronic orchitis can be asymptomatic and may impact fertility through T-cell-mediated autoimmune disruption of spermatogenesis 6