Epididymoorchitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Epididymoorchitis refers to the inflammation of the epididymis and/or testes, with or without infection. It is a major cause of acute scrotum and must be differentiated from other common causes, such as testicular torsion and torsion of the testicular appendage. While the pathogenesis is not fully understood, infectious epididymoorchitis is thought to be due to retrograde reflux of infected urine into the epididymis, which then spreads to the testes. The causes of epididymoorchitis can be divided into idiopathic, infectious and non-infectious causes. Most common cases are due to infectious causes, which are mostly due to N. gonorrhea, C. trachomatis and E. Coli. Data on epidemiology of epididymoorchitis is scarce, however, epididymoorchitis is the 5th most common genitourinary diagnosis made and disease is more prevalent among U.S. military men. Peak incidence of the disease is in men between the ages of 20 to 29 years. The main symptoms of epididymoorchitis are scrotal pain and swelling. Other symptoms such as fever, nausea, vomiting and lower UTI symptoms may be present. The main focus of physical examination in patients with epididymoorchitis is scrotal and testicular examination. Signs that may be present include testicular swelling, tenderness on palpation, as well as erythema. Other signs include relief of pain upon elevation of the testis. Unlike patients with testicular torsion, patients with epididymoorchitis have an intact cremasteric reflex. A color Doppler ultrasound is mainly done to rule out testicular torsion and is the diagnostic imaging of choice in evaluating cases of acute scrotum. Epididymoorchitis might show a thickened epididymis with normal to increased Doppler wave pulsations, consistent with normal to increased blood flow. Management of epididymoorchitis consists mainly of conservative measures, including bed rest and limitation of physical activity, use of cold packs, analgesia and non-steroidal anti-inflammatory drugs (NSAIDs). In addition, appropriate antibiotic therapy should be initiated if the cause of epididymoorchitis is bacterial.

Cases of epididymoorchitis were described in literature as early as 1841.^[1] It was believed that epididymitis was caused by chemical irritation caused by urine reflux. However, by 1979, a study showed that bacteria were responsible for more cases.^[2]

Epididymoorchitis can be classified based on the extent of involvement into isolated cases of epididymitis, isolated cases of orchitis or cases of epididymoorchitis. Another means of classifying the disease is based on duration into acute or chronic epididymoorchitis. Finally, it can also be classified according to the causative agent into infectious, non-infectious and idiopathic causes.^[2][3]

Epididymoorchitis refers to the inflammation of the epididymis and/or testes, with or without infection. While the pathogenesis is not fully understood, infectious epididymoorchitis is thought to be due to retrograde reflux of infected urine into the epididymis, which then spreads to the testes.^[2][3]

The causes of epididymoorchitis can be divided into idiopathic, infectious and non-infectious causes.^[4][3]

Epididymoorchitis is a major cause of acute scrotum. Other causes of acute scrotum which must be differentiated from epididymoorchitis include testicular torsion and torsion of the testicular appendage.^[2][5][4][6]

Data on epidemiology of epididymoorchitis is scarce, however, epididymoorchitis is the 5th most common genitourinary diagnosis made and disease is more prevalent among U.S. military men. Peak incidence of the disease is in men between the ages of 20 to 29 years.^[4]

Risk factors for epididymoorchitis include sexual activity and sexually transmitted diseases, surgery or instrumentation of the bladder, as well as anatomic abnormalities of the urinary tract and obstruction to the normal flow of urine.^[2]

There are no screening recommendations for epididymoorchitis.^[7]

The prognosis of epididymoorchitis is usually excellent, with the majority of cases resolving within 30 days of initiation of medical therapy. However, some cases can progress to chronic epididymoorchitis. Other complications of epididymoorchitis include abscess formation, testicular infarction, sepsis and infertility.

The main symptoms of epididymoorchitis are scrotal pain and swelling. Other symptoms such as fever, nausea, vomiting and lower UTI symptoms may be present.^[2][8][5][4]

The main focus of physical examination in patients with epididymoorchitis is scrotal and testicular examination. Signs that may be present include testicular swelling, tenderness on palpation, as well as erythema. Other signs include relief of pain upon elevation of the testis. Unlike patients with testicular torsion, patients with epididymoorchitis have an intact cremasteric reflex.

In patients with epididymoorchitis, laboratory investigations include a urinalysis, urine culture, as well as urethral Gram stain and PCR testing for N. gonorrhea and C. trachomatis.

There are no x-ray findings associated with epididymoorchitis.

Imaging studies, such as CT scan, are usually not done in the case of epididymoorchitis. The diagnostic modality of choice is a scrotal ultrasound.

Imaging studies, such as MRI, are usually not done in the case of epididymoorchitis. The diagnostic modality of choice is a scrotal ultrasound.

A color Doppler ultrasound is mainly done to rule out testicular torsion^[3] and is the diagnostic imaging of choice in evaluating cases of acute scrotum.^[4] Epididymoorchitis might show a thickened epididymis with normal to increased Doppler wave pulsations, consistent with a normal to increased blood flow.

A scrotal radionuclide scintigraphy has a high specificity and sensitivity in distinguishing between testicular torsion and epididymoorchitis. In testicular torsion, there is decreased or absent uptake of radionuclide, while uptake is increased in cases of epididymoorchitis.^[3]

There are no other diagnostic studies for epididymoorchitis.

Management of epididymoorchitis consists mainly of conservative measures, including bed rest and limitation of physical activity, use of cold packs, analgesia and non-steroidal anti-inflammatory drugs (NSAIDs). In addition, appropriate antibiotic therapy should be initiated if the cause of epididymoorchitis is bacterial.^[2][8][3]

There is no role for surgery in treating uncomplicated cases of epididymoorchitis.

In men aged 14 to 35 years, cases of epididymoorchitis are mainly due to sexually transmitted infections. Hence, the importance of condom use to prevent the disease should be emphasized.^[2]

Secondary prevention of epididymoorchitis mainly consists on emphasizing on the importance of completion of the antibiotic course if prescribed, screening and treating comorbid sexually transmitted infections in both the patient and his partners.^{[2][4][9][10][11]}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Cases of epididymoorchitis were described in literature as early as 1841.^[1]It was believed that epididymitis was caused by chemical irritation caused by urine reflux. However, by 1979, a study showed that bacteria were responsible for more cases. ^[2]

• Cases of epididymoorchitis were described in literature as early as 1841.^[1]
• In 1841, A. J. Taylor described the effects of compression (i.e., applying pressure on the testicles) in the treatment of epididymitis.^[1] In 1847, Wills GF suggests the same modality of treatment for orchitis.^[3]
• In 1906, Francis R. Hagner described operative treatment of acute epididymitis caused by N. gonorrhea.^[4]
• It was believed that epididymitis was caused by chemical irritation caused by urine reflux. However, by 1979, a study showed that bacteria were responsible for more cases. ^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Epididymoorchitis can be classified based on the extent of involvement into isolated cases of epididymitis, isolated cases of orchitis or cases of epididymoorchitis. Another means of classifying the disease is based on duration into acute or chronic epididymoorchitis. Finally, it can also be classified according to the causative agent into infectious, non-infectious and idiopathic causes.^[1][2]

Epididymoorchitis can be classified based on the extent of involvement, duration or cause of the disease.^[1][2]

• Epididymitis
• Orchitis
• Epididymoorchitis

Epididymoorchitis can be divided into acute and chronic epididymoorchitis based on duration of the illness:

• Acute epididymoorchitis: are cases lasting less than 6 weeks in duration
• Chronic epididymoorchitis: are cases lasting more than 3 months in duration

There are several etiological factors to epididymoorchitis and these include:

• Infectious causes
• Noninfectious causes
• Idiopathic epididymoorchitis

For more on the causative agents of epididymoorchitis, click here

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Epididymoorchitis refers to the inflammation of the epididymis and/or testes, with or without infection. While the pathogenesis is not fully understood, infectious epididymoorchitis is thought to be due to retrograde reflux of infected urine into the epididymis, which then spreads to the testes.^[1][2]

Epididymoorchitis refers to the inflammation of the epididymis and/or testes, with or without infection. While the pathogenesis is not fully understood, the following are the proposed mechanisms behind epididymoorchitis:^[1][2]

• The retrograde ascent of infectious pathogens is the usual route of infection. Most cases of epididymoorchitis start with inflammation of the epididymis (i.e., epididymitis), which then spread to the adjacent testicle (i.e., orchitis). Because orchitis tends to occur in patients with concurrent epididymitis, cases are mostly referred to as epididymoorchitis.
• Isolated cases of orchitis are usually due to mumps virus and in isolated cases of orchitis, blood-borne dissemination is the usual route of infection.
• Retrograde flow of infected urine into the ejaculatory duct is thought to cause epididymoorchitis.
• For infectious cases of epididymoorchitis that are not associated with an STD or UTI, it is believed that these cases may be related a post-infectious inflammatory reaction. When taking viral cultures of throat, stool and urine, it was found that patients with epididymoorchitis had elevated titers to certain pathogens, as compared to controls. Most notably, patients with epididymoorchitis had elevated titers to M. pneumonia and adenovirus.
• The mechanism behind non-infectious epididymoorchitis remains unclear.

• 
  Image on the left shows evidence of acute inflammation and exudates on the surface of the testicle. Image to the right is a cut section showing exudates and dense fibrosis in the epididymis. Adapted from https://commons.wikimedia.org/wiki/Category:Gross_pathology_of_epididymo-orchitis#/media/File:Acute_epidydimoorchitis_Gross_Pathology.jpg. Accessed on Jan 3rd, 2017.
• 
  Cut-section through the testicle following orchidectomy showing a lesion in the epidydimis with fibrosis and caseous necrosis, following chronic epididymoorchitis caused by Mycobacterium tuberculosis. Adapted from https://commons.wikimedia.org/wiki/Category:Gross_pathology_of_tuberculous_epididymo-orchitis#/media/File:Tuberculous_epididymoorchitis_gross_pathology.jpg. Accessed on Jan 3rd, 2017.

Acute epididymoorchitis is characterized by infiltration of neutrophils. Chronic cases of epididymoorchitis, such as in sarcoidosis or tuberculosis, are characterized by granulomatous inflammation.

• 
  Microscopy showing hyalinised residual seminiferous tubules and dense infilitrate of neutrophils. Adapted from https://commons.wikimedia.org/wiki/Category:Histopathology_of_epididymo-orchitis#/media/File:Suppurative_epidydimo_orchitis_histopathology.jpg. Accessed on Jan 3rd, 2017.
• 
  Low-power microscopy showing tuberculous epididymitis; caseous necrosis surrounded by epithelioid cells and giant cells with a mantle of lymphocytes. Adapted from https://commons.wikimedia.org/wiki/Category:Histopathology_of_tuberculous_epididymitis#/media/File:Tuberculous_epididymitis_Low_Power.jpg. Accessed on Jan 3rd, 2017.

The following conditions may be associated with epididymoorchitis:^[1]

• Sexually transmitted diseases, such as N. gonorrhea and C. trachomatis
• Mumps infection may be associated with isolated cases of orchitis
• Anatomic abnormalities of the urinary tract, such as prostatic obstruction in older men (e.g., benign prostatic hyperplasia (BPH), prostatic cancer, urethral strictures)^[2] and posterior urethral valves or meatal stenosis in young, prepubertal boys

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

The causes of epididymoorchitis can be divided into idiopathic, infectious and non-infectious causes.^[1][2]

The causes of epididymoorchitis can be divided into idiopathic, infectious and non-infectious causes:^[1][2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]Syed Hassan A. Kazmi BSc, MD [3]José Eduardo Riceto Loyola Junior, M.D.[4]

Epididymoorchitis is a major cause of acute scrotum. Other causes of acute scrotum which must be differentiated from epididymoorchitis include testicular torsion and torsion of the testicular appendage.^[1][2][3][4]

Epididymoorchitis is a major cause of acute scrotum. Other causes of acute scrotum which must be differentiated from epididymoorchitis include testicular torsion and torsion of the testicular appendage:^[1][2][3][4]

• If patient presents with symptoms for ≥6-weeks (symptoms of discomfort or pain in the scrotum, testicle, or epididymis), chronic epididymitis must be suspected. It is usually caused by granulomatous reaction. Mycobacterium tuberculosis is the most common granulomatous disease affecting the testicles and epididymis. Differential must include chronic noninfectious epididymitis.

Epididymoorchitis should be differentiated from other conditions presenting with scrotal pain or lower abdominal pain, fever, nausea and vomiting. The differentials include the following:^{[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Data on epidemiology of epididymoorchitis is scarce, however, epididymoorchitis is the 5th most common genitourinary diagnosis made and disease is more prevalent among U.S. military men. Peak incidence of the disease is in men between the ages of 20 to 29 years.^[1]

Data on epidemiology of epididymoorchitis is scarce, however, epididymoorchitis is the 5th most common genitourinary diagnosis made and disease is more prevalent among U.S. military men.^[1]

• In 2002, 1 in 144 outpatient visits were due to epididymoorchitis.^[2]
• In 2002, it has been estimated that the incidence of epididymoorchitis in the U.S. is 600,000 cases per year.^[2]

The true prevalence of epididymoorchitis is unknown.^[3]

• Epididymoorchitis can occur in men of any age. However, there is a bimodal distribution for the disease between 16-30 years of age and 51-70 years of age.^[2]
• Peak incidence for epididymoorchitis is in men between the ages of 20-29 years.^[2][1]

No sufficient data exists on racial predilection of epididymoorchitis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Risk factors for epididymoorchitis include sexual activity and sexually transmitted diseases, surgery or instrumentation of the bladder, as well as anatomic abnormalities of the urinary tract and obstruction to the normal flow of urine.^[1]

Risk factors for epididymoorchitis include:^[1]

• Sexual activity and infection with sexually transmitted diseases, such as C. trachomatis and N. gonorrhea
• Males who have sex with males (MSM)
• HIV is a risk factor to epididymoorchitis infections caused by viruses and fungi
• Strenuous physical activity^[2][3]
• Riding motorcycles/bicycles^[2][3]
• Prolonged periods of inactivity and sitting^[2][3]
• Recent urinary tract surgery or instrumentation, such as cystoscopy and bladder catheterization^[4]
• Anatomic abnormalities of the urinary tract, such as prostatic obstruction in older men (e.g., benign prostatic hyperplasia (BPH), prostatic cancer, urethral strictures)^[5] and posterior urethral valves or meatal stenosis in young, prepubertal boys
• Mumps infection is a risk factor for isolated mumps orchitis infection

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

There are no screening recommendations for epididymoorchitis.^[1]

There are no screening recommendations for epididymoorchitis.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

The prognosis of epididymoorchitis is usually excellent, with the majority of cases resolving within 30 days of initiation of medical therapy. However, some cases can progress to chronic epididymoorchitis. Other complications of epididymoorchitis include abscess formation, testicular infarction, sepsis and infertility.

If left untreated, acute epididymoorchitis may progress to chronic cases.^[1]

Some of the complications of an acute epididymoorchitis infection include:^[1]

• Progression of the infection to chronic epididymoorchitis
• Formation of a reactive hydrocele
• Abscess formation
• Infarction of the testicle
• Sepsis
• Infertility

The prognosis of epididymoorchitis is usually excellent. In young patients in whom epididymoorchitis is due to a sexually transmitted disease, acute epididymoorchitis usually resolves within 2 weeks of the initiation of medical therapy. In men older than the age of 40, 90% of cases of epididymitis resolve within 30 days of treatment.^[2]

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