Orchitis

Source:
M. Mycyk, E-medicine

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.

Frequency:

• In the US: Approximately 20% of prepubertal patients with mumps develop orchitis. This condition rarely occurs in postpubertal males with mumps. Bacterial orchitis is even more rare, and it usually is 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, there is little evidence supporting 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 (under 10 y).

• In bacterial orchitis, most cases are associated with epididymitis (epididymo-orchitis), and they occur in sexually active males over 15 y or in men over 50 y 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 d.

• A sexual history should be obtained, 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

• Stool for occult blood

• Other:

• Parotitis

• Fever

Causes:

• Most commonly, mumps causes isolated orchitis.

• The onset of scrotal pain and edema is acute.

• As 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 d.

• Other rare viral etiologies include Coxsackie virus, infectious mononucleosis, varicella, and echovirus.

• Some case reports have described mumps orchitis following immunization with the MMR (mumps, measles, and rubella) vaccine.

• Bacterial causes, usually spread from an associated epididymitis in sexually active men or men with BPH, 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.

  Treatment:
  
  Emergency Department Care:
  

  • Supportive treatment:
  • Bed rest
  • Hot or cold packs for analgesia
  • Most importantly, the ED physician must rule out testicular torsion, as the two syndromes often present with similar symptoms.
  • Second, the ED physician should consider epididymo-orchitis and, if highly suspected, treat appropriately.

  Consultations:
  

  • If torsion is likely, urological consultation is required for urgent surgical exploration.
  • If a significant hydrocele is detected or suspected, urological consultation is necessary to evaluate the need for a surgical tapping to relieve the pressure on the tunica.
  • Follow-up with the urologist is appropriate for an uncomplicated presentation of orchitis.

Medication:

• 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 under 35 y and sexually active, antibiotic coverage for sexually transmitted pathogens (particularly gonorrhea and chlamydia) with ceftriaxone and either doxycycline or azithromycin is appropriate. Patients over 35 y with a bacterial etiology require additional coverage for other gram-negative bacteria with a fluoroquinolone or TMP-SMX. Other appropriate medications include analgesics or anti-emetics, as needed.

Or*chi"tis (?), n. [NL., fr. Gr. a testicle + -itis.] Med.

Inflammation of the testicles.

© Webster 1913.