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.