Epididymo-orchitis

Acute disease

Inflammation confined to the epididymis is epididymitis; when infection spreads to the body of the testis, the condition is known as epididymo-orchitis.

Mode of infection

Infection reaches the globus minus of the epididymis via the lumen of the vas from a primary infection of the urethra, prostate or seminal vesicles. In men with outflow obstruction, epididymitis may result from a secondary urinary infection a high pressure in the prostatic urethra causes reflux of infected urine up the vasa. A noninfective epididymitis sometimes arises from a similar cause when unusual exertion or violent strain when the bladder is full causes injection of urine into the vasa under pressure. In young men, the most common sexually transmitted infection causing epididymitis is now chlamydia but gonococcal epididymitis is still prevalent. Both are associated with urethritis. Blood-borne infections of the epididymis are less common but may be suspected when there is Escherichia coli, streptococcal, staphylococcal or proteus infection without evidence of urinary infection.

Clinical features

The initial symptoms are those of acute prostatitis. Some days later an ache in the groin and a fever herald the onset of epididymitis. The epididymis and testis swell rapidly and become exquisitely painful. The scrotal wall which is at first red, oedematous and shiny may become adherent to the epididymis. Resolution is signalled by scaling of the scrotal skin and may take 6—8 weeks to complete. Occasionally the infection may go on to abscess formation and discharge of pus may occur through the scrotal skin.

Acute epididymo-orchitis can follow any form of urethral instrumen­tation. It is particularly common when there is an indwelling catheter and an associated infection of the prostate. The incidence of acute postoperative epididymitis which was a serious and frequent complica­tion of prostatectomy has been greatly reduced by closed drainage, catheter care and the early use of antibiotics.

Acute tuberculous epididymitis should come to mind when the vas is thickened and there is little response to the usual antibiotics.

Acute epididymo-orchitis of mumps develops in about 18 per cent of males suffering from mumps, usually as the parotid swelling is waning. The main complication is testicular atrophy which may cause infertility if the condition is bilateral (which is not usual). Partial atrophy is associated with persistent testicular pain. The epididymitis of mumps sometimes occurs in the absence of parotitis, especially in infants. The epididymis and testis may be involved by infection with other entero­viruses and in brucellosis and lymphogranuloma venereum.

Treatment

The patient should rest in bed while the acute symptoms per­sist. Doxycycline (100 mg daily) is the treatment of choice for young men with chlamydial infection. If an organism is isolat­ed from the urine, this simplifies the choice of antibiotic. Otherwise treatment should be with an agent that is active across a broad spectrum of urinary tract pathogens. The patient should drink plenty of fluid. Local measures can help to reduce pain. The scrotum is supported on a sling made of broad adhesive tape attached between the thighs. The inflam­ed organ rests on a pad of cotton wool placed on the sling.

Antibiotic treatment should continue for 2 weeks or until the inflammation has subsided. If suppuration occurs, drainage is necessary. The patient should be warned that the testis may atrophy.

Chronic disease

Chronic tuberculous epididymo-orchitis usually begins insidiously.

Aetiology. The frequency with which the globus is first attacked indicates that the infection is retrograde from a tuberculous focus in the seminal vesicles.

Clinical features. Typically there is a firm discrete swelling of the lower pole of the epididymis which aches a little. The disease progresses until the whole epididymis is firm and craggy behind a normal-feeling testis. There is a lax secondary hydrocele in 30 per cent and in some a characteristic beading of the vas is apparent due to subepithelial tubercles. The seminal vesicle feels indurated and swollen. In neglected cases a tuberculous ‘cold’ abscess forms which may discharge. The body of the testis may be uninvolved for years but the contralateral epididymis often becomes diseased.

In two-thirds of cases there is evidence of renal tuberculosis or previous disease. The other patients appear healthy.

The urine and semen should be examined repeatedly for tubercle bacilli in all patients with chronic epididymo-orchitis. An intravenous urogram and a chest X-ray should be performed.

Treatment. When the epididymitis is secondary, it may resolve when the primary tuberculous focus is treated.

Treatment with antituberculous drugs is less effective in genital tuberculosis than in urinary tuberculosis. If resolution does not occur within 2 months, epididymectomy or orchidectomy is advisable. A full course of antiruberculous chemotherapy should be completed even if there is no evidence of disease elsewhere.

Chronic nontuberculous epididymitis usually follows the failure of an acute attack to resolve fully. The condition is difficult to distinguish from tuberculosis but the swelling may be larger and smoother. It is essential to exclude urethral stricture causing reflux of urine down the vas. If alternative granulomatous conditions such as sarcoidosis have been eliminated, chronic epididymitis should be treated with antibiotics. Epididymectomy or orchidectomy should be considered if there is no resolution after 4—6 weeks of conservative treatment.

Orchitis. Syphilitic orchitis affects the body of the testis and is now uncommon. There are three varieties:

  bilateral orchitis is a feature of congenital syphilis;

  interstitial fibrosis causes painless destruction of the testis;

  gumma of the testis presents as a unilateral painless swelling of the testis which grows slowly. It feels hard and heavy and is very difficult to distinguish from a neoplasm without surgical exploration.

Leprous orchitis causes testicular atrophy in over 25 per cent of male lepers.