BACTERIAL INFECTIONS

Acute epididymo-orchitis

Empirical antibiotic treatment

Chlamydia trachomatis/non-gonococcal, non-enteric organisms
Doxycycline, 100 mg p.o. b.d. for 1014 days5
Neisseria gonorrhoeae
One of the following
Ceftriaxone, 250 mg i.m. stat5
Ciprofloxacin, 500 mg p.o. stat (if sensitivity to ciprofloxacin
confirmed on culture)5
plus
Doxycycline, 100 mg p.o. b.d. for 1014 days5
Enteric organisms
Ofloxacin, 200 mg p.o. b.d. for 14 days6 (can also be used in
the above infections, if sensitivity to quinolones confirmed on
gonorrhoea culture)
or
Ciprofloxacin, 500 mg p.o. b.d. for 10 days7

Rachel A Lee
Janet D Wilson

Aetiology
Acute epididymo-orchitis is primarily an infection of the epididymis,
sometimes with secondary orchitis. In men under 35 years, it is
usually caused by sexually transmitted bacteria, commonly
Chlamydia trachomatis or Neisseria gonorrhoeae.1 Mycoplasma
genitalium and Ureaplasma urealyticum have been implicated,
though evidence for these as common causes is lacking.2
In men over 35 years, acute epididymo-orchitis is more commonly a complication of a urinary tract infection (UTI) caused
by a Gram-negative enteric organism such as Escherichia coli.3
Such infections are also likely in those with urinary tract abnormalities or following urinary tract instrumentation. Men engaging
in unprotected anal intercourse are also at increased risk of
epididymo-orchitis secondary to infection with enteric organisms.4
STIs are not uncommon in men over the age of 35 years, and it is
essential to take a good sexual history in all cases.
Mycobacterium tuberculosis is a rarer infective cause of acute
epididymo-orchitis, though it usually results in a more chronic
presentation. Non-infective epididymo-orchitis may occur in
Behets disease and with amiodarone treatment.

the diagnosis of epididymo-orchitis. Typical Gram-negative intracellular diplococci are seen in N. gonorrhoeae infection.
Gonorrhoea urethral swab for culture or first-void urine for an
N. gonorrhoeae nucleic acid amplification test (NAAT) is taken.
Chlamydia a first-void urine sample or urethral swab is taken
for a C. trachomatis NAAT.
Mid-stream urine is taken for microscopy and culture.

Management
Non-steroidal anti-inflammatory drugs and a scrotal support are
recommended for symptom relief. Empirical antibiotics should be
given, depending on the most likely causative organism (Figure 1).
When an STI is suspected, sexual partners should be screened and
treated empirically. Patients should be advised to abstain from
sexual intercourse until treatment is complete.
Patients should be followed-up carefully to ensure resolution
of symptoms and signs. Those who do not respond adequately to
treatment should be reassessed promptly, to exclude abscess and
other diagnoses (e.g. testicular torsion, tumour).

Clinical features
The most common presenting symptom of acute epididymo-orchitis
is unilateral testicular pain. Preceding dysuria and urethral discharge may suggest an STI, but such symptoms are often absent.1
There may be symptoms suggesting the presence of a UTI (e.g.
urinary frequency, urgency, dysuria, haematuria).
On examination, there is usually tenderness of the affected side,
particularly the epididymis, which may be swollen. There may be
generalized swelling of the testicle, with oedema and erythema
of the overlying scrotal skin. Systemic features such as fever and
rigors are most commonly seen in Gram-negative infections. There
may be an associated hydrocele.

REFERENCES
1 Mulcahy F M et al. Prevalence of chlamydial infection in acute
epididymitis. Genitourin Med 1987; 53: 1618.
2 Taylor-Robinson D. Mycoplasma genitalium an update. Int J STD
AIDS 2002; 13: 14551.
3 Hawkins D A et al. Microbiological survey of acute epididymitis.
Genitourin Med 1986; 62: 3424.
4 Barnes R et al. Urinary tract infections in sexually active homosexual
men. Lancet 1986; i: 1713.
5 Hooson A A et al. Microbiology of acute epididymitis in a developing
country. Genitourin Med 1993; 69: 3613.
6 Melekos M D, Asbach H W. Epididymitis: aspects concerning etiology
and treatment. J Urol 1987; 138: 836.
7 Eickhoff J H et al. A double-blind randomised, controlled multicentre
study to compare the efficacy of ciprofloxacin with pivampicillin as
oral therapy for epididymitis in men over 40 years of age. BJU Int
1999; 84: 82734.

Investigations
The following investigations are recommended.
Gram-stained urethral smear is taken for microscopy. Urethritis
is diagnosed by the presence of five or more neutrophils per highpower field ( 1000). The absence of urethritis does not exclude

Rachel A Lee is Consultant in Genitourinary Medicine at Leeds General

Infirmary, Leeds, UK. Conflicts of interest: none.
Janet D Wilson is Consultant in Gentourinary Medicine at Leeds General
Infirmary, Leeds, UK. Conflicts of interest: none.

MEDICINE 33:10

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2005 The Medicine Publishing Company Ltd