By definition, orchitis is inflammation of the testis, but the term has been used to describe testicular pain localized to the testis without objective evidence of inflammation. Acute orchitis represents sudden occurrence of pain and swelling of the testis associated with acute inflammation of that testis. Chronic orchitis involves inflammation and pain in the testis, usually without swelling, persisting for more than 6 weeks. A classification (Nickel and Beiko, 2001) based on etiology is presented in Table 11–8.
Table 11–8 Classification of Orchitis
Isolated orchitis is a relatively rare condition and is usually viral in origin. It spreads to the testis by a hematogenous route. Most cases of orchitis, particularly bacterial, occur secondary to local spread of an ipsilateral epididymitis and are referred to as epididymo-orchitis. UTIs are usually the underlying source in boys and elderly men. In young sexually active men, sexually transmitted diseases are often responsible (Berger, 1998). Truly noninfectious orchitis is often idiopathic or related to trauma, although autoimmune disease has rarely been implicated (Pannek and Haupt, 1997). It may be impossible to clinically distinguish chronic orchitis from chronic orchialgia.
Bacterial orchitis is usually associated with epididymitis and is therefore often caused by urinary pathogens, including E. coli and Pseudomonas. Less commonly, Staphylococcus species or Streptococcus species are responsible. The most common sexually transmitted microorganisms responsible are Neisseria gonorrhoeae, C. trachomatis, and Treponema pallidum. Xanthogranulomatous orchitis, usually associated with Proteus and E. coli, is an extremely rare inflammatory destructive lesion of the testes that is treated with orchiectomy (Kang et al, 2007; Al-Said et al, 2007).
Mycobacterial infections, tuberculosis (Chen et al, 2004; Park et al, 2008), and bacillus Calmette-Guérin therapy (Hill et al, 2008) can also cause orchitis. The most common cause of viral orchitis is mumps (Jalal et al, 2004; Masarani et al, 2006; Emerson et al, 2007), but infectious mononucleosis has also been implicated (Weiner, 1997). Fungal infections occasionally involve the testis, with candidiasis, aspergillosis, histoplasmosis, coccidiomycosis, blastomycosis, and actinomycosis all having been reported as causes of orchitis (Wise, 1998). Parasitic infections rarely cause orchitis in the Western Hemisphere, but filariasis (Hazen Smith and von Lichtenberg, 1998) and trypanosomiasis (Ehrhardt et al, 2006) have been described in some endemic areas of Africa, Asia, and South America.
In patients presenting with acute infectious orchitis, history discloses a recent onset of testicular pain, often associated with abdominal discomfort, nausea, and vomiting. These symptoms may be preceded by symptoms of parotitis in boys or young men, by UTIs in boys or elderly men, or alternatively by symptoms of a sexually transmitted disease in sexually active men. Although the process is usually unilateral, it is sometimes bilateral, especially if viral. Physical examination may reveal a toxic and febrile patient. The skin of the involved hemiscrotum is erythematous and edematous, and the testis is quite tender to palpation or can be associated with a transilluminating hydrocele. The patient should be clinically assessed for prostatitis and urethritis. For acute noninfectious orchitis the clinical picture resembles the just-presented description except that these patients lack the toxic appearance and fever.
For chronic orchitis and orchialgia there may have been a history of previous episodes of testicular pain, usually secondary to acute bacterial orchitis, trauma, or other causes. The patient has chronic testicular (and possibly epididymal) pain to a degree that could seriously affect his day-to-day functioning and quality of life. Patients with this diagnosis usually become very frustrated with this problem. On examination the patient does not appear toxic and does not have a fever. The scrotum is not usually erythematous, but the testis may be somewhat indurated and is almost always tender to palpation.
Laboratory tests employed to assist in the diagnosis include urinalysis, urine microscopy, and urine culture. For a patient in whom a sexually transmitted disease is suspected, a urethral swab should also be taken for culture. If the diagnosis is not evident from the history, physical examination, and these simple tests, scrotal ultrasonography should be performed (to rule out malignancy in patients with chronic orchitis/orchialgia). The most important differential diagnosis in young men and boys is testicular torsion. Testicular torsion is often difficult to differentiate from an acute inflammatory condition. Scrotal ultrasound evaluations (with use of Doppler imaging to determine testicular blood flow) are especially helpful in differential diagnosis (Mernagh et al, 2004; Gunther et al, 2006), but occasionally the diagnosis will be missed (particularly with intermittent or partial torsion) and the clinician should err in favor of the surgically correctable diagnosis of torsion.
General principles of therapy include bed rest, scrotal support, hydration, antipyretics, anti-inflammatory agents, and analgesics. Antibiotic therapy (specific for UTI, prostatitis, or sexually transmitted diseases) should be employed for infectious orchitis and is ideally based on culture and sensitivity testing but may be based on microscopic or Gram stain results. There are no specific antiviral agents available to treat orchitis caused by mumps, and the previously mentioned supportive measures are important. If early testing is negative or results are unavailable, empirical treatment should be initiated, directed at the most likely pathogens based on the available clinical information: a fluoroquinolone would be the best agent in this scenario. Most patients can be readily managed on an outpatient basis. Surgical intervention is rarely indicated, unless testicular torsion (or rarely xanthogranulomatous orchitis) is suspected (as discussed previously). Spermatic cord blocks with injection of a local anesthetic may sometimes be needed to relieve the patient of severe pain. Abscess formation is rare, but if it does occur then percutaneous or open drainage is necessary.
Treatment of chronic orchitis/orchialgia is supportive. Anti-inflammatory agents, analgesics, support, heat therapies, and nerve blocks all have a role in ameliorating symptoms. It is generally believed that the condition is self-limited but could take years (and sometimes decades) to resolve. Orchidectomy is indicated only in cases in which pain control is refractory to all other measures (and even this might not be successful in alleviating the chronic pain) (Nariculam et al, 2007).
Epididymitis by definition is inflammation of the epididymis. Acute epididymitis represents sudden occurrence of pain and swelling of the epididymis associated with acute inflammation of the epididymis (Nickel et al, 2002). Chronic epididymitis refers to inflammation and pain in the epididymis, usually without swelling (but with induration in long-standing cases), persisting for over 6 weeks (Nickel et al, 2002). Inflammation is not always clinically evident in many cases of localized epididymal pain. Approximately 1 man in 100 attending a North American urology clinic has a diagnosis of epididymitis (Nickel et al, 2005c). In the late 1990s the average cost per episode of epididymitis managed in the United States was 368 dollars (Gift and Ownes, 2006), a cost considerably less than that reported for men with a diagnosis of chronic prostatitis. A classification for epididymitis is presented in Table 11–9 (Nickel et al, 2002).
Table 11–9 Classification of Epididymitis
Acute epididymitis usually results from the spread of infection from the bladder, urethra, or prostate via the ejaculatory ducts and vas deferens into the epididymis. The process starts in the tail of the epididymis and then spreads through the body of the structure to the head of the epididymis. In infants and boys, epididymitis is often related to a UTI and/or an underlying genitourinary congenital anomaly (Merlini et al, 1998) or even to the presence of a foreskin (Bennett et al, 1998). In elderly men, BPH and associated stasis, UTI, and catheterization is the most common cause of epididymitis. Bacterial prostatitis and/or seminal vesiculitis are associated with epididymal infection in postpubertal males of all ages (Furuya et al, 2004). In sexually active men younger than 35 years of age, epididymitis is commonly the result of a sexually transmitted infection (Berger, 1998). In most cases of acute epididymitis, the testis is also involved in the process and thus the condition is referred to as epididymo-orchitis.
Chronic epididymitis may result from inadequately treated acute epididymitis, recurrent epididymitis, or some other cause including associations with other disease processes such as Behçet disease (Cho et al, 2003; Arromdee and Tanakitivirul, 2006; Pektas et al, 2008) or treatment with amiodarone (Nikolaou et al, 2007). The etiology of chronic epididymalgia is usually unclear. Certainly one of the best known and studied is the chronic epididymitis/epididymalgia that occurs in some men after a vasectomy. About 1 in 100 men describe severe pain 6 months after a vasectomy that noticeably affects their quality of life (up to 15% of men report some discomfort 6 months after the procedure) (Leslie et al, 2007).
The most common causative microorganisms in the pediatric and elderly age groups are the coliform organisms that cause bacteriuria (Berger et al, 1979). In men younger than the age of 35 who are sexually active with women, the most common offending organisms causing epididymitis are the usual bacteria that cause urethritis, namely N. gonorrhoeae, and C. trachomatis. In homosexual men practicing anal intercourse, E. coli and Haemophilus influenzae are most commonly responsible. Both tuberculosis (Lui et al, 2005; Tsili et al, 2008) and mycobacteria, such as bacillus Calmette-Guérin (Harada et al, 2006), can be associated with epididymitis. As with orchitis, viral, fungal, mycoplasmal, and parasitic microorganisms have all been implicated in epididymitis (Berger, 1998; Wise, 1998; Hazen Smith and von Lichtenberg, 1998; Scagni et al, 2008). Rarely, epididymitis as a complication of brucellosis has been described (Akinci et al, 2006; Queipo-Ortuno et al, 2006; Colmenero et al, 2007).
Both acute infectious and acute noninfectious epididymitis present in much the same way as do acute infectious and acute noninfectious orchitis, respectively. Physical examination localizes the tenderness to the epididymis. However, in many cases the testis is also involved in the inflammatory process and subsequent pain and this is referred to as epididymo-orchitis. The spermatic cord is usually tender and swollen. Early on in the process, only the tail of the epididymis is tender, but the inflammation quickly spreads to the rest of the epididymis and if it continues to the testis then the swollen epididymis becomes indistinguishable from the testis.
There may be no clinical or etiologic differentiation between chronic epididymitis and epididymalgia. The patient usually presents with a long-standing history of pain (waxing and waning or constant) localized to the epididymis, and like chronic orchitis/orchialgia these symptoms may have a significant impact on the patient’s quality of life (Nickel et al, 2002).
Laboratory tests should include Gram staining of a urethral smear and a midstream urine specimen. Gram-negative bacilli can usually be identified in patients with underlying cystitis. If the urethral smear reveals the presence of intracellular gram-negative diplococci, a diagnosis of infection with N. gonorrhoeae is established. If only WBCs are seen on the urethral smear, a diagnosis of C. trachomatis will be established two thirds of the time. A urethral swab and midstream urine specimen should be sent for culture and sensitivity testing. When an infant or young boy is diagnosed with epididymitis he should be further evaluated with abdominopelvic ultrasonography, voiding cystourethrography, and possibly cystoscopy (Shortliffe, 1998; Al-Taheini et al, 2008). If the diagnosis is uncertain, duplex Doppler scrotal ultrasonography to look for increased blood flow to the affected epididymis may be performed (also to rule out torsion as described under orchitis) (Mernagh et al, 2004). Ultrasonography can sometimes be helpful to rule out other epididymal and scrotal pathology (Lee et al, 2008).
Management of acute infectious epididymitis depends on the likely cause and organism (Tracy et al, 2008). The Centers for Disease Control and Prevention’s 2006 guidelines for the treatment of infectious epididymitis includes ceftriaxone or doxycycline for men younger than age 35 years and levofloxacin or ofloxacin for men older than age 35 years (Centers for Disease Control and Prevention et al, 2006).
For chronic epididymitis, a 4- to 6-week trial of antibiotics that would potentially be effective against possible bacterial pathogens and particularly C. trachomatis may be appropriate (Nickel, 2005). Anti-inflammatory agents, analgesics, scrotal support, and nerve blocks have all been recommended as empirical treatment (Nickel, 2005). It is generally believed that chronic epididymitis is a self-limited condition that will eventually “burn out,” but this could take years (or even decades). Surgical removal of the epididymis (epididymectomy) should be considered only when all conservative measures have been exhausted and the patient accepts that the operation will have at best a 50% chance of curing his pain (Padmore et al, 1996; Tracy et al, 2008). However, better surgical results (up to 70%) have been reported for epididymectomy for postvasectomy pain (Siu et al, 2007).
Key Points
Orchitis and Epididymitis
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