Orchitis: Difference between revisions

Latest revision as of 20:45, 17 August 2023

Background

Scrotal anatomy

Adult testicle with epididymis (left is posterior): A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens.

Inflammation of testis - can be infectious (usually) or non-infectious
Infectious
- Viral - most common etiology is mumps (orchitis seen in 20-30% of mumps patients)^[1]
  - Epididymis typically not involved
- Bacterial - typically due to hematogenous spread from epididymis: "epididymo-orchitis"
  - (bacterial infections rarely involve only the testis)
  - bacterial pathogens: N. gonorrhea, C. trachomatis, E. Coli, Klebsiella, P. aeruginosa

Clinical Features

Testicular tenderness, edema
May see erythema of overlying scrotum
Viral orchitis
- Abrupt onset of scrotal pain/swelling 4-7 days after onset of parotitis^[1]
- Usually unilateral
Fever, tachycardia
Inguinal lymphadenopathy
Patient uncomfortable while seated

Differential Diagnosis

Testicular Diagnoses

Evaluation

Doppler ultrasound of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased.

Work-Up

Testicular ultrasound
Urinalysis and urine culture
May also consider GC, Chlamydia cultures

Evaluation

Combination of clinical features and results of imaging/UA
Ultrasound may show inflammation, epididymitis, and rules out active torsion
Urinalysis positive for infection in epididymo-orchitis

Management

Viral orchitis (mumps): supportive care, cold packs, scrotal elevation, analgesia.
Bacterial orchitis (epididymo-orchitis):
- <35yo (assume sexually transmitted):
  - Ceftriaxone 250mg IM x1 AND
  - Doxycycline 100mg PO BID x14 days OR Azithromycin 1gm x1
  - Also treat sexual partner
- >35yo, NO history of anal intercourse and NOT sexually active:
  - Ofloxacin 300mg PO BID x14 days OR levofloxacin 500mg QD x10 days OR ciprofloxacin 500mg PO BID x14 days
  - IV: piperacillin/tazobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6

Disposition

Generally may be discharged home

References

↑ ^1.0 ^1.1 Trojian, Thomas H., Timothy S. Lishnak, and Diana Heiman. "Epididymitis and orchitis: an overview." Am Fam Physician 79.7 (2009): 583-587.

Authors:

[Trojian-1] 1.0 ^1.1 Trojian, Thomas H., Timothy S. Lishnak, and Diana Heiman. "Epididymitis and orchitis: an overview." Am Fam Physician 79.7 (2009): 583-587.

[1]

@@ Line 1: / Line 1: @@
 ==Background==
-#rare acute infection of testis
+[[File:Gray1144.png|thumb|Scrotal anatomy]]
-#most common in prepubertal boys with viral infections (20% of patients with mumps)
+[[File:Epididymis-KDS.jpg|thumb|Adult testicle with epididymis (left is posterior): A. Head of epididymis, B. Body of epididymis, C. Tail of epididymis, and D. Vas deferens.]]
-##arises several days after onset of flu-like symptoms and parotitis in mumps patients
+*Inflammation of testis - can be infectious (usually) or non-infectious
-##Epididymis not involved; usually unilateral
+*Infectious
-#bacterial orchitis typically due to spread from epididymis: epididymo-orchitis
+**[[Viral syndrome|Viral]] - most common etiology is [[mumps]] (orchitis seen in 20-30% of mumps patients)<ref name="Trojian">Trojian, Thomas H., Timothy S. Lishnak, and Diana Heiman. "Epididymitis and orchitis: an overview." Am Fam Physician 79.7 (2009): 583-587.</ref>
-##bacterial pathogens: N. gonorrhea, c. trachomatis, E. Coli, Klebsiella, P. aeruginosa
+***Epididymis typically not involved
-##Differentiate from viral orchitis by involvement of epididymis, abscence of preceding parotid sx
+**Bacterial - typically due to hematogenous spread from [[Epididymitis|epididymis]]: "epididymo-orchitis"
-#presents with fever and scrotal pain
+***(bacterial infections rarely involve only the testis)
+***bacterial pathogens: ''[[N. gonorrhea]], [[C. trachomatis]], [[E. Coli]], [[Klebsiella]], [[P. aeruginosa]]''
-==Diagnosis==
+==Clinical Features==
-#affected testicle/scrotum: swollen, tender, erythematous
+*Testicular tenderness, edema
-#testicular US shows testicular inflammation, rules out torsion, epididymitis
+*May see erythema of overlying scrotum
-#UA: positive in epididymo-orchitis
+*Viral orchitis
+**Abrupt onset of scrotal pain/swelling 4-7 days after onset of parotitis<ref name="Trojian" />
+**Usually unilateral
+*[[Fever]], [[tachycardia]]
+*Inguinal [[lymphadenopathy]]
+*Patient uncomfortable while seated
-==Work-Up==
+==Differential Diagnosis==
-#testicular US
+{{Testicular DDX}}
-#UA, Urine Culture, gonorrhea, chlamydia screen
-==DDx==
+==Evaluation==
-===Types of Orchitis===
+[[File:Ultrasonography of epididymitis.jpg|thumb|Doppler ultrasound of epididymitis, seen as a substantial increase in blood flow in the left epididymis (top image), while it is normal in the right (bottom image). The thickness of the epididymis (between yellow crosses) is only slightly increased.]]
-#Mumps (or other viral) orchitis
+===Work-Up===
-#Lupus orchitis
+*Testicular ultrasound
+*[[Urinalysis]] and urine culture
+*May also consider GC, Chlamydia cultures
-===Other Diagnoses===
+===Evaluation===
-{{Template:Testicular DDX}}
+*Combination of clinical features and results of imaging/UA
+*[[Testicular ultrasound|Ultrasound]] may show inflammation, epididymitis, and rules out active torsion
+*[[Urinalysis]] positive for infection in epididymo-orchitis
-==Treatment==
+==Management==
-#viral orchitis (mumps): supportive care, ice, elevation, analgesia.
+*Viral orchitis (mumps): supportive care, cold packs, scrotal elevation, [[analgesia]].
-#bacterial orchitis (epididymo-orchitis):
+*Bacterial orchitis (epididymo-orchitis):
-##sexually transmitted (<35yo):
+**<35yo (assume sexually transmitted):
-###[[ceftriaxone]] 250mg IM x1 or cipro 500mg PO x1 for [[gonorrhea]]
+***[[Ceftriaxone]] 250mg IM x1 '''AND'''
-###doxycycline 100mg PO BID x 14 days for [[chlamydia]]
+***[[Doxycycline]] 100mg PO BID x14 days '''OR''' [[Azithromycin]] 1gm x1
-##anal intercourse, nonsexually active, instrumentation and/or >35yo:
+***Also treat sexual partner
-###cipro 500mg PO BID x 14 days OR ofloxacin 200mg PO BID x 14 days
+**>35yo, NO history of anal intercourse and NOT sexually active:
-###IV: piperacillin/taxobactam 3.375g IV q6 or ampicillin/sulbactam 3g IV q6
+***Ofloxacin 300mg PO BID x14 days '''OR''' [[levofloxacin]] 500mg QD x10 days '''OR''' [[ciprofloxacin]] 500mg PO BID x14 days
-#treat sexual partner
+***IV: [[piperacillin/tazobactam]] 3.375g IV q6 or [[ampicillin/sulbactam]] 3g IV q6
 ==Disposition==
-#admit for signs of systemic toxicity
+*Generally may be discharged home
 ==See Also==
 *[[Testicular Diagnoses]]
-==Source==
+==References==
-*Rosen's
+<references/>
-*ER Atlas
-[[Category:GU]]
+[[Category:Urology]]
 [[Category:ID]]