8.3 Epididymitis and orchitis

8.3.1 Epidemiology

Definition and nomenclature: Epididymitis, inflammation of the epididymis, causes pain and swelling which is almost always unilateral and relatively acute in onset (33). In some cases, the testis is involved in the inflammatory process (epididymo-orchitis). On the other hand, inflammatory processes of the testicle, especially virally induced orchitis, often involve the epididymis.

Orchitis and epididymitis are classified as acute or chronic processes according to the onset and clinical course (34). Chronic disease with induration develops in 15% of acute epididymitis cases. In the case of testicular involvement, chronic inflammation may result in testicular atrophy and the destruction of spermatogenesis (35).

Incidence and prevalence: There are no new precise data available concerning the incidence and prevalence of epididymitis. According to older data, acute epididymitis was a major cause for admission to hospitals of military personnel (34). Acute epididymitis in young males is associated with sexual activity and infection of the consort (36).

The most common type of orchitis, mumps-orchitis, develops in 20-30% of post-pubertal patients undergoing mumps infection. The incidence depends upon the vaccination status of the population (37). A primary chronic orchitis is the granulomatous disease, a rare condition with uncertain aetiology reported in about 100 cases in the literature (38).

8.3.2 Morbidity

Complications in epididymo-orchitis include abscess formation, testicular infarction, testicular atrophy, development of chronic epididymal induration and infertility (34).

Epididymitis caused by sexually transmitted organisms occurs mainly in sexually active males aged < 35 years (34,39). The majority of cases of epididymitis are due to common urinary pathogens, which are also the most common cause of bacteriuria (34,39). Bladder outlet obstruction and urogenital malformations are risk factors for this type of infection.

8.3.3 Pathogenesis and pathology

Typically, in epididymitis due to common bacteria and sexually transmitted organisms, the infection is spread from the urethra or bladder. In non-specific granulomatous orchitis, auto-immune phenomena are assumed to trigger chronic inflammation (35,38). Orchitis of the child and mumps-orchitis are of haematogenous origin (35). Epididymo-orchitis is also seen in systemic infections such as tuberculosis, lues, brucellosis and cryptococcus disease.

8.3.4 Clinical features

In acute epididymitis, the inflammation and swelling usually begin in the tail of the epididymis, and may spread to involve the rest of the epididymis and testicular tissue. The spermatic cord is usually tender and swollen. All men with epididymitis that results from sexually transmitted organisms have a history of sexual exposure, which can lie dormant for months before the onset of symptoms. If the patient is examined immediately after obtaining a urinalysis, urethritis and urethral discharge may be missed because WBC and bacteria have been washed out of the urethra during urination.

The microbial aetiology of epididymitis can usually be determined by examination of a Gram stain of a urethral smear and/or an MSU for the detection of Gram-negative bacteriuria. The presence of intracellular Gram-negative diplococci on the smear correlates with an infection of N. gonorrhoeae. The presence of only WBC on a urethral smear indicates the presence of non-gonorrhoic urethritis. C. trachomatis will be isolated in approximately two-thirds of these patients (34,39).

Ejaculate analysis according to WHO criteria including leucocyte analysis may indicate persistent inflammatory activity. In many cases, transient decreased sperm counts and forward motility can be found. Azoospermia due to a complete obstruction of both epididymis is a rare complication (40). If mumps-orchitis is suspected, a history of parotitis and evidence of IgM antibodies in the serum supports the diagnosis. In about 20% of mumps-orchitis cases, the disease occurs bilaterally in post-pubertal men with a risk of testicular atrophy and azoospermia (36).

8.3.5 Differential diagnosis

It is imperative for the physician to differentiate between epididymitis and spermatic cord torsion as soon as possible using all available information, including the age of the patient, history of urethritis, clinical evaluation and Doppler (duplex) scanning of testicular blood flow.

8.3.6 Treatment

Only a few studies have been performed measuring the penetration of antimicrobial agents into epididymis and testis in human. Of these, the fluoroquinolones have shown favourable properties (41).

Antimicrobials should be selected on the empirical basis that in young, sexually active men C. trachomatis is usually causative, and that in older men with BPH or other micturition disturbances, the most common uropathogens are involved. Studies comparing microbiological results from puncture of the epididymis and from urethral swabs as well as urine have shown very good correlation. Therefore, prior to antimicrobial therapy, a urethral swab and MSU should be obtained for microbiological investigation.

Again, fluoroquinolones, preferably those with activity against С trachomatis (e.g. ofloxacin and levofloxacin), should be the drugs of first choice, because of their broad antibacterial spectra and their favourable penetration into the tissues of the urogenital tract. If С trachomatis has been detected as an aetiological agent, treatment could also be continued with doxycycline, 200 mg/day, for a total treatment period of at least 2 weeks. Macrolides may be used as alternative agents.

Supportive therapy includes bed rest, uppositioning of the testes and antiphlogistic therapy. Since, for young men, epididymitis can lead to permanent occlusion of the epididymal ducts and thus to infertility, one should consider antiphlogistic therapy with methylprednisolone, 40 mg/day, and reduce the dose by half every second day.

In case of С trachomatis epididymitis, the sexual partner should also be treated. If uropathogens are found as causative agents, a thorough search for micturition disturbances should be carried out to prevent relapse. Abscess-forming epididymitis or orchitis also needs surgical treatment. Chronic epididymitis can sometimes be the first clinical manifestation of urogenital tuberculosis.