Epididymo-Orchitis Empiric Therapy

Epididymo-orchitis is a condition that is characterized by inflammation of testis or/and epididymis. In vast majority of cases, Epididymo-orchitis is a result of sexually transmitted infections or ascending urinary tract infections. Although, the condition is fairly discomforting; yet the risk of complications is generally low, especially if the treatment is sought early.

What are Some Primary Causes of Epididymo-Orchitis?

Most frequently reported causes of Epididymo-orchitis include:

• Ascending Urinary Infections: Bacteria like E. coli are a leading cause of urinary tract infections that may lead to epididymo-orchitis in poorly managed cases. It is most common in men over the age of 35 years of age. The primary pathophysiology revolves around the physiological enlargement of prostate gland or narrowing of urethra leading to partial obstruction of urinary flow.

• Sexually Transmitted Infection: It is another common cause mostly in younger men. Common infections that affect the urethra (leading to urethritis) are: chlamydia and gonorrhoea. In some males, the infection further spreads to the testis and epididymis.

• Mumps Virus: The virus finds its way to the testes via the haematogenous spread. It is not a very common cause because of the widespread availability of vaccines. Epididymo-orchitis due to mumps is more common in younger children and is also characterized by swelling of parotid salivary glands.

• Surgery of Urethra or Prostate: It is not a common cause due to advanced aseptic measures used in most surgical procedures. The prostate removal often allows invasion of bacteria within the urethra that may cause epididymo-orchitis as a likely complication.

• Medications: A medicine known as Amiodarone when given in doses exceeding 200mg, is known to aggravate the risk of epididymo-orchitis as a potential side effect.

• Other Causes: Some other infections like tuberculosis and brucellosis (or other infectious agents in the blood) can also travel throughthe blood stream to cause epididymo-orchitis. Other infectious diseases that may cause epididymo-orchitis include Behcet’s disease and schistosomiasis disease. Direct physical trauma or injury to the scrotum can also aggravate the risk of epididymo-orchitis.

Who is at Risk of Getting Epididymo-Orchitis?

According to latest statistics, the incidence of epididymo-orchitis is 1 in 1,000 males. Men between the age of 15-30 or elderly males (over the age of 60 years) are at much higher risk. Based on clinical data, the risk of developing epididymo-orchitis is rare before puberty; however, 3 out of 10 boys, who get infected by mumps virus after puberty, are likely to develop orchitis. Catheter or insertion of other instrument in the male urethra may also put you at higher risk.

Symptoms of Epididymo-Orchitis

The onset of symptoms is usually sudden. The testis and epididymis become rapidly swollen and the scrotum becomes red, tender and enlarged. Most patients present with localized pain and signs of inflammation. Other common symptoms include:

• Pain while urinating
• Discharge from penis (in case of urethral infection)
• Fever

Diagnostic Tests

Test for bacteria: if urine infection is suspected, urine test is done. If sexually transmitted infection is suspected, a sample from urethra is collected to be tested for STIs. If you have epididymo-orchitis as a result of sexually transmitted infection, your partner should also get tested and treated to minimize the risk of recurrence.

Complications

There are usually no complications but in some rare cases; patients may develop:

• Accumulation of pus in the scrotum due to infection. A minor operation may be needed to drain the pus
• The fertility of the affected testis may be affected especially if the cause is mumps virus
• Development of chronic inflammation
• Testis may become eriously damaged and tissue death may occur such as gangrene of the testes. This would require surgical removal.

Empiric Treatment

Given below is the empiric treatment of epididymo-orchitis according to the most likely cause.

• General recommendations: the causes behind acute epididymo-orchitis may be idiopathic, non-infectious, nonbacterial or bacterial. If the cause is bacterial infection then empiric antibiotic therapy is started before the identification of pathogen.
• STI: treatment focuses on eradication of Chlamydia trachomatis and Neisseria gonorrhoeae. A single IM ceftriaxone injection of 250-500mg along with Azithromycin 1g PO/or/ doxycycline 100mg PO twice daily for 7-14 days may be used. It is recommended to avoid sex for 7 days after the initiation of treatment or to use condoms. To minimize the chances of re-infection, sexual partners should also be evaluated.
• Urinary pathogens: usually gram negative enteric organisms tend to cause epididymo-orchitis in men above 35 years of age. Floroquinolones is usually the preferred antibiotics if an enteric organism is suspected, because of their enhanced penetration into testes. Given below are the recommended regimens:
• Amoxicillin-clavulanate 500mg thrice daily for 10 days. or
• Trimethoprim-sulfamethoxazole 160/800mg 1 DS tablet PO twice daily for 10 days. or
• Ofloxacin 200mg PO twice daily for 10 days or
• Levofloxacin 500mg PO daily for 10 days or
• Ciprofloxacin 500mg PO twice daily for 10-14 days or
• Enteric organism infection in prepubertal males:
• Amoxicillin-clavulanate 15-20mg/kg PO q12h- 10 days
• Trimethoprim-sulfamethoxazole 3-6mg/kg PO q12h- 10 days
• Supportive/adjunctive therapy: minimize physical activity; provide scrotal elevation and support, use cold-packs and anti-inflammatory agents to relive inflammation. Use nerve blocks and analgesics. Prevent using urethral instrumentation. Use sitz bath.

References:

1. Fehily, S. R., Trubiano, J. A., McLean, C., Teoh, B. W., Grummet, J. P., Cherry, C. L., & Vujovic, O. (2015). Testicular loss following bacterial epididymo-orchitis: Case report and literature review. Canadian Urological Association Journal, 9(3-4), E148.
2. Blach, O., Ali, A., Goubet, S., Nawrocki, J., Richardson, D., & Thomas, P. (2015). Management of epididymo-orchitis in three different clinical settings: Streamlining pathways and improving care. Journal of Clinical Urology, 2051415815586489.