Background
Orchitis is an acute inflammatory
reaction of the testis secondary to infection. Most cases are associated with a
viral
mumps infection; however, other viruses and bacteria can cause orchitis.
Pathophysiology
Hippocrates first reported the
syndrome in the 5th century BC. While the more common epididymo-orchitis is
bacterial in origin, isolated orchitis usually has a viral etiology.
Epidemiology
Frequency
United
States
Approximately 20% of prepubertal
patients with mumps develop orchitis. This condition has become increasingly
common in adolescent and postpubertal males with mumps, especially in the last
decade with a reduction in use of the measles, mumps, rubella (MMR) vaccine.
Isolated bacterial orchitis is even more rare and is usually associated with a
concurrent epididymitis.
Mortality/Morbidity
- Unilateral testicular atrophy occurs in 60% of patients with orchitis.
- Sterility is rarely a consequence of unilateral orchitis.
- Despite some anecdotal reports, little evidence supports an increased likelihood of developing a testicular tumor after an episode of orchitis.
Age
- In mumps orchitis, 4 out of 5 cases occur in prepubertal males (younger than 10 years).
- In bacterial orchitis, most cases are associated with epididymitis (epididymo-orchitis), and they occur in sexually active males older than 15 years or in men older than 50 years with benign prostatic hypertrophy (BPH).
History
- Orchitis is characterized by testicular pain and swelling.
- The course is variable and ranges from mild discomfort to severe pain.
- Associated systemic symptoms
- Fatigue
- Malaise
- Myalgias
- Fever and chills
- Nausea
- Headache
- Mumps orchitis follows the development of parotitis by 4-7 days.
- Obtain a sexual history, when appropriate.
Physical
- Testicular examination
- Testicular enlargement
- Induration of the testis
- Tenderness
- Erythematous scrotal skin
- Edematous scrotal skin
- Enlarged epididymis associated with epididymo-orchitis
- Rectal examination
- Soft boggy prostate (prostatitis) often associated with epididymo-orchitis
- Other
- Parotitis
- Fever
Causes
- Most commonly, mumps causes isolated orchitis.
- The onset of scrotal pain and edema is acute.
- Because mumps orchitis is responsible for most cases of isolated orchitis, diagnosis in the ED usually is based on a reported history of a recent mumps infection or parotitis with a presentation of testicular edema.
- Mumps orchitis presents unilaterally in 70% of cases.
- In 30% of cases, contralateral testicular involvement follows by 1-9 days.
- Other rare viral etiologies include coxsackievirus, infectious mononucleosis, varicella, and echovirus.
- Some case reports have described mumps orchitis following immunization with the mumps, measles, and rubella (MMR) vaccine.
- Bacterial causes usually spread from an associated epididymitis in sexually active men or men with BPH; bacteria include Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus and Streptococcus species.
- Bacterial orchitis rarely occurs without an associated epididymitis.
- Patients are usually sexually active and present with a gradual onset of pain and edema.
- Unilateral testicular edema occurs in 90% of cases.
- Immunocompromised patients have been reported to have orchitis with the following etiologic agents: Mycobacterium avium complex, Cryptococcus neoformans, Toxoplasma gondii, Haemophilus parainfluenzae, and Candida albicans.
Differential Diagnoses
Laboratory Studies
- Laboratory tests are not helpful in making the diagnosis of orchitis in the ED.
- Diagnosing mumps orchitis can be comfortably made based on history and physical examination alone. However, if epididymo-orchitis is a concern, urine dip, urinalysis, and urethral cultures should be obtained.
- Diagnosing mumps orchitis can be confirmed with serum immunofluorescence antibody testing.
Imaging Studies
- Color Doppler ultrasonography has become the imaging test of choice for the evaluation of an acute scrotum.[1, 2]
- Because orchitis often presents as acute edema and pain of the testicle, ruling out testicular torsion is critical.
- Often the history and the physical examination are enough; however, as an adjunct, ultrasonography is highly sensitive for ruling out testicular torsion and for demonstrating inflammation of the testis or the epididymis.[3, 4]
Procedures
- If torsion is likely or if several hours have passed before the patient arrives in the ED, operative exploration is indicated.
- Orchitis complicated by a reactive hydrocele or pyocele may require surgical drainage to reduce the pressure in the tunica.
Emergency Department Care
- Supportive treatment
- Bed rest
- Hot or cold packs for analgesia
- Scrotal elevation
- Most importantly, the ED physician must rule out testicular torsion, as the two syndromes often present with similar symptoms.[5]
- Second, the ED physician should consider epididymo-orchitis and, if highly suspected, treat appropriately.
Consultations
- If torsion is likely, urologic consultation is required for urgent surgical exploration.
- If a significant hydrocele is detected or suspected, urologic consultation is necessary to evaluate the need for a surgical tapping to relieve the pressure on the tunica.
- Follow-up care with a urologist is appropriate for an uncomplicated presentation of orchitis.
Medication Summary
No medications are indicated for the treatment of viral orchitis.Bacterial orchitis or epididymo-orchitis requires appropriate antibiotic coverage for suspected infectious agents. In patients with a bacterial etiology who are younger than 35 years and sexually active, antibiotic coverage for sexually transmitted pathogens (particularly gonorrhea and chlamydia) with ceftriaxone[6] and either doxycycline[6] or azithromycin is appropriate. Fluoroquinolones are no longer recommended by the Centers for Disease Control and Prevention (CDC) for treatment of gonorrhea because of resistance. For more information see, CDC updated gonococcal treatment recommendations (April 2007).
Patients older than 35 years with bacterial etiology require additional coverage for other gram-negative bacteria with a fluoroquinolone or TMP-SMX. Other appropriate medications include analgesics or antiemetics, as needed.
Antibiotics
Class Summary
Therapy must cover all likely pathogens in the context of the clinical setting.Ceftriaxone (Rocephin)
Doxycycline (Vibramycin, Doryx)
Used in combination with ceftriaxone for the treatment of gonorrhea.
Azithromycin (Zithromax)
Indicated for chlamydia and gonorrheal infections of the genital tract.
Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)
Ofloxacin (Floxin)
Ciprofloxacin (Cipro)
Further Outpatient Care
- Supportive therapy
- Bed rest
- Scrotal support
- Analgesics
- Hot or cold packs for analgesia: Elevation of the scrotum and placement of ice on the affected testis are specific comfort measures that should be recommended to the patient with orchitis. The patient should put a small pillow or a towel between the legs to elevate the scrotum and place ice on the affected testis for 10-15 minutes, 4 times a day, until pain resolves.
- Patients with a suspected sexually transmitted disease should be referred to their private physician or local health department for HIV testing.
Complications
- Up to 60% of affected testes demonstrate some degree of testicular atrophy.
- Impaired fertility is reported at a rate of 7-13%.
- Sterility is rare in cases of unilateral orchitis.
- An associated hydrocele or pyocele may require surgical drainage to relieve pressure from the tunica.
Prognosis
- Most cases of mumps orchitis resolve spontaneously in 3-10 days.
- With appropriate antibiotic coverage, most cases of bacterial orchitis resolve without complication.
Patient Education
- Patients with a suspected sexually transmitted disease should be counseled on safe sex practices.
- For excellent patient education resources, visit eMedicine's Men's Health Center, Bacterial and Viral Infections Center, and Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Inflammation of the Testicle (Orchitis), Mumps, and Sexually Transmitted Diseases.
BY BERIC
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