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European guideline for the management of
epididymo-orchitis and syndromic
management of acute scrotal swelling
ARTICLE in INTERNATIONAL JOURNAL OF STD & AIDS · NOVEMBER 2001
Impact Factor: 1.04 · DOI: 10.1258/0956462011924010 · Source: PubMed

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. gonorrhoeae and/or C. gram-negative intracellular diplococci should be looked for to exclude the diagnosis of gonorrhoea. This may be associated with a history suggestive of bladder out¯ow obstruction There is cross-over between these groups and complete sexual history-taking is imperative1. 3): 88±93 MANAGEMENT OF SYNDROMES European guideline for the management of epididymo-orchitis and syndromic management of acute scrotal swelling P J Horner Bristol Royal In®rmary.9±11. 12 (Suppl.5. Tenderness to palpation on the affected side Palpable swelling of the epididymis.horner@bristol. Laboratory The following investigations should be undertaken1: . . In men younger than 35 years-of-age epididymoorchitis is most often caused by sexually transmitted pathogens such as Chlamydia trachomatis and Neisseria gonorrhoeae1±14 In men older than 35 years-of-age epididymoorchitis is most often caused by non-sexually transmitted Gram-negative enteric organisms causing urinary tract infections1±14. UK INTRODUCTION .21.15±16 Gram-negative enteric organisms are more commonly the cause of epididymo-orchitis if recent instrumentation or catheterization has occurred1. . . They may also have: . in experienced hands A Gram-stained urethral smear containing 55 PMNL per high-power (61000) microscopic ®eld (averaged over 5 ®elds with greatest concentration of PMNLs).International Journal of STD & AIDS 2001. Urethral discharge Dysuria Penile irritation. General The presence of a sexually transmitted pathogen is frequently associated with a new sexual partner or more than one sexual partner in the recent past.ac. .17±20 Anatomical abnormalities of the urinary tract are common in the group infected with Gramnegative enteric organisms and further investigation of the urinary tract should be considered in all such patients but especially in those older than 50 years1. trachomatis22 Either a urethral smear or a ®rst-pass urine specimen can be used to detect urethritis by con®rming an excess of polymorphonuclear leucocytes (PMNLs) In patients with urethritis. DIAGNOSIS . Urethral discharge (this may only be present on urethral massage) Hydrocoele Erythema and/or oedema of the scrotum on the affected side Pyrexia. . . . Clinical Symptoms (these are usually unilateral) . Symptoms of urethritis (this is often asymptomatic10. . and/or The identi®cation of 510 PMNL per highpower (61000) microscopic ®eld (averaged over 5 ®elds with greatest concentration of PMNLs) on a Gram-stained preparation from a ®rst-passed urine (FPU) specimen . . This has a sensitivity of 490% for detecting gonococcal infection. . Testicular pain Scrotal swelling. . Symptoms of bladder out¯ow obstruction may also be present. Signs Ð on examination patients are usually found to have: .11.uk 88 Standard sexually transmitted disease (STD) examination as in guideline on non-gonococcal urethritis (NGU) to look for presence of urethritis and/or N.13±14 Epididymo-orchitis caused by sexually transmitted enteric organisms also occurs in homosexual men who engage in insertive anal intercourse1. . . . . Bristol.14): E-mail: paddy.

. It should be considered in all patients and should be excluded ®rst as testicular salvage becomes decreasingly likely with time32.15 O¯oxacin 200 mg twice daily for 14 days9. Non-steroidal anti-in¯ammatory drugs may be helpful34. Torsion of the spermatic cord (testicular torsion) is the main differential diagnosis. . trachomatis General advice . Cipro¯oxacin 500 mg stat 250 mg intramuscularly. gonorrhoeae C. If tetracycline resistance is common o¯oxacin may be preferable. Torsion of the testis Epididymo-orchitis secondary to N. gonorrhoeae or NGU including C. . . Nevertheless. See guideline on management of urethritis22. . using a dipstick which contains leucocyte esterase and nitrites. and analgesics are recommended. . The onset of pain is sudden The pain is severe Tests performed during the initial visit show neither the presence of a urethritis nor likely UTI The patient is younger than 20 years-of-age (the peak incidence is in adolescents). any recent instrumentation or catheterization and any known urinary tract abnormalities in the patient Bed rest.37. in addition to blood protein and glucose. . . Indications for therapy . The presence of an observable mucopurulent/ purulent urethral discharge is also indicative of urethritis2. The presence of blood in the MSU is usually the result of taking a urethral smear. Recommended regimens . . a positive nitrite test is very speci®c although its sensitivity is only 40±80%27 MSU for microscopy and bacterial culture. Consideration should be given to: . but it can occur at any age32. indeed a positive leucocyte esterase test in the FPU specimen is indicative of urethritis. Recommended regimens . the sexual history. although this has a poor sensitivity2. . .24±26). . . Symptoms and signs of epididymo-orchitis Urethritis detected UTI not suspected.33. The antibiotic regimen chosen should be determined in the light of the immediate tests as well as the age of the patient.35 If torsion is suspected an urgent urological opinion must be sought. or ceftriaxone Antibiotics used for gonorrhoea may need to be varied according to local knowledge of antibiotic sensitivities. . . Doxycycline 100 mg twice daily for 14 days7. Torsion is more likely if: . scrotal elevation and support. However. O¯oxacin 200 mg twice daily for 14 days Trimethoprim 200 mg twice daily for 14 days Antibiotics used may need to be varied according to local knowledge of antibiotic sensitivities. .Horner. Epididymo-orchitis secondary to enteric organism General advice The following should be discussed and clear written information provided: . For epididymo-orchitis where gonococcal infection is suspected. they have not been assessed speci®cally in a STD clinic23. Management of epididymo-orchitis and acute scrotal swelling . Epididymo-orchitis secondary to N. Differential diagnosis . . Empirical therapy should be given to all patients with epididymo-orchitis before micro- . These dipsticks are an established screening test for bacterial urinary tract infections (UTI). trachomatis Epididymo-orchitis secondary to enteric organisms Testicular or epididymal tumour. A detailed explanation of what epididymoorchitis is and what causes it Side-effects of treatment and importance of complying fully with it and what to do if a dose is missed. . either of the following in addition to doxycycline should be given: . trachomatis should also be sought Urinalysis of the mid-stream urine (MSU) specimen. this cannot reliably differentiate between gonococcal and NGU and the absence of such a discharge does not exclude urethritis A urethral culture for N. MANAGEMENT General . and positive leucocyte esterase activity may re¯ect urethritis and not a UTI. Thus the results of these for diagnosing a UTI should be viewed with scepticism.36. gonorrhoeae or NGU including C. However. It is a surgical emergency.33. Colour Doppler ultrasound is useful to help differentiate between epididymo-orchitis and torsion of the spermatic cord28±31. Indications for therapy . 89 biological results are available11. . symptoms and signs of epididymo-orchitis UTI strongly suspected.

. O¯oxacin 200 mg twice daily for 14 days. Symptoms and signs of epididymo-orchitis Unable to differentiate between sexually transmitted pathogen or non-sexually transmitted enteric organism as the aetiological agent. since: Ð No test is 100% sensitive for detecting C. Of importance in the management is the syndromic detection of urethritis. gonorrhoeae or NGU including C. . . This ensures that if the index patient does not reattend. 3 months is suggested The treatment regimen used should be as detailed for uncomplicated C. was wrong and patient was therefore treated incorrectly Enteric organism resistant to therapy with trimethoprim or o¯oxacin Abscess formation and/or scrotal ®xation Testicular or epididymal tumour Mumps epididymo-orchitis Tuberculous epididymitis Fungal epididymitis Gonococcal infection resistant to ¯uoroquinolones and tetracycline. Torsion of the spermatic cord (testicular torsion) is the main differential diagnosis. . . . trauma and a testicular or epididymal tumour.e. FOLLOW UP If there is no improvement in the patient's condition after 3 days then the diagnosis should be reassessed and therapy re-evaluated.90 International Journal of STD & AIDS Volume 12 Supplement 3 October 2001 Epididymo-orchitis of indeterminate aetiology . gonorrhoeae are found to be positive. and a possible reduction in female morbidity. the patient's follow-up in addition should include that as detailed in the guideline for urethritis. . . . . . Surgical assessment may be appropriate in these cases41. trachomatis is diagnosed Epididymo-orchitis of indeterminate aetiology is diagnosed and the subsequent MSU specimen is negative This needs to be handled sensitively and the con®dentiality of the index patient maintained. . Differential diagnoses to consider in these circumstances include1: . MANAGEMENT OF PARTNERS All sexual partners at risk should be assessed and offered epidemiological treatment if: . Testicular ischaemia/infarction Initial diagnosis of infective aetiology. A detailed explanation of what epididymoorchitis is and what causes it and the dif®culty in initially establishing the exact cause Side-effects of treatment and importance of complying fully with it and what to do if a dose is missed Advised to abstain from sexual intercourse until the microbiological results from the MSU specimen are available. although in some cases symptoms take longer than this to settle. trachomatis or N. Without recourse to diagnostic facilities it may be dif®cult to differentiate between these. he can be contacted and/or provider referral can be initiated for sexual contacts Contact(s) of men with chlamydial or gonococcal epididymo-orchitis should be treated regardless of results of microbiological investigations Concurrent treatment of the sexual partners of men with chlamydia-negative and/or gonococcal-negative epididymo-orchitis is recommended as it may result in improved response in some patients. trachomatis in men Ð There is evidence that at least some men with `chlamydia-negative' NGU have partners who are chlamydia-positive40. The ¯ow-chart (Figure 1) details the syndromic management of this condition. The duration of look-back is arbitrary as the incubation period of epididymo-orchitis is unknown. General advice The following should be discussed and clear written information provided: . trachomatis or N. Recommended regimens . Epididymo-orchitis secondary to N. Indications for therapy . i. trachomatis infection38 and include treatment for uncomplicated gonorrhoea39 if this is isolated from the index case If C. If urethritis is detected the most likely aetiology is epididymo-orchitis secondary to N. .42. gonorrhoeae are detected it is particularly important to ensure that all sex partner(s) potentially at risk have been noti®ed Details of all contacts should be obtained at the ®rst visit. . . . Consent should also be obtained to contact either the patient or his partners if tests for C. torsion. trachomatis is diagnosed. trachomatis. SYNDROMIC MANAGEMENT OF ACUTE SCROTAL SWELLING The principal diagnoses are epididymo-orchitis. with a repeat examination for urethritis at 2 weeks22. . Reassessment is required if signs of swelling and tenderness persist after antimicrobial therapy is completed. It is a surgical emergency. gonorrhoeae or NGU including C. gonorrhoeae or NGU including C. If epididymo-orchitis secondary to N. enteric organism versus STI. . It should be considered in all patients and should be excluded ®rst as testicular salvage becomes decreasingly likely with time.

Management of epididymo-orchitis and acute scrotal swelling 91 Figure 1. the urethra should be gently massaged from the ventral . If none is seen. The use of urinary dipsticks containing nitrites. Syndromic management of acute scrotal swelling (see text) How to do this is detailed in the guideline on the management of urethritis22 and summarized below. Diagnosis of urethritis Ð clinical . because of their speci®city for detecting UTIs.Horner. would also be of clinical bene®t (see above). Men should be examined for evidence of a urethral discharge.

Mucopurulent or purulent discharge observable on examination. 1998 guidelines for treatment of sexually transmitted diseases. Lennox KW. Resistant gonococcal infection is likely to be more of a problem in countries where syndromic STI management guidelines are widely 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Clinical Effectiveness Group. Harris JR. 1997 [http://www. Investigations Microscope present: . Monda GD. Nevertheless. Aetiology of acute epididymitis. J Urol 1979. Sex Trans Dis 1984. McCormick G. Van der Meijden WI..19:257±61 Mittemeyer BT. J Infect 1989. Genitourin Med 1986. Plante P. Blacklock NJ. the infection also involves the posterior urethra. The role of Chlamydia trachomatis in epididymitis. Holmes KK. The foreskin should be retracted fully and the patient asked to urinate into two clean specimen glasses. Lancet 1977. for the reason detailed above.124: 60±1 Humphreys H. It is an essential part of management. or Positive two-glass urine test.62:76±8 Hoosen AA. The frequency of Chlamydia trachomatis in acute epididymitis. Alexander ER. part of the penis towards the meatus. Holmes KK.63:16±18 Grant JB. J Urol 1987. but the second will be clear. Borski AA. See guideline on urethritis22 Gram stain for Gram-negative diplococci to exclude gonorrhoea. Rajakumar R. Daifuku R. Mayo ME.298:301±4 Kristensen JK. the severity of urethritis cannot differentiate reliably between gonococcal and NGU.i:171±3 Berger RE. the rest into the second.11:32±3 Melekos MD. et al. . J Urol 1980. Bignell CJ. Scheibel JH. Br J Urol 1987.60: 355±9 DeJong Z. and this has been undertaken by an experienced operator. bladder or kidneys. Harnisch JP. Alexander ER.121:750±4 Harnish JP. Etiology and manifestations of epididymitis in young men: correlations with sexual orientation.154:209±13 Berger RE.i:819±21 Berger RE. manifestations and therapy of acute epididymitis: prospective study of 50 patients. J Urol 1995. References 1 2 3 Microscope absent: . Pontonnier F.nl] Krieger JN. Reed R. The differential diagnoses for patients who fail to respond to therapy is as detailed previously. Prevalence of chlamydial infection in acute epididymo-orchitis. the ®rst 10±20 ml into one glass. . Thomas BJ. Utrecht: Stichting SOA-bestrijding. eds. Etiology. Etiology of acute epididymitis presenting in a venereal disease clinic. Cairo I. cipro¯oxacin 500 mg can be omitted from the regimen: `doxycycline 100 mg twice daily (BD) for 14 days plus cipro¯oxacin 500 mg stat'. used43. Speller DC. Sexually Transmitted Diseases: Netherlands Diagnosis and Therapy Guidelines 1997. Alexander ER.92 International Journal of STD & AIDS Volume 12 Supplement 3 October 2001 . Genitourin Med 1993. If microscopy has been used to diagnose urethritis. N Engl J Med 1978. Microbiology of acute epididymitis in a developing country. National guideline for the management of epididymo-orchitis. Sequeira PJ. Costello CB.62:342±4 Mulcahy FM. Roddy R. Holmes KK. This can be undertaken by the patient The absence of urethral discharge does not exclude urethritis In gonococcal infection the discharge is usually more evident and purulent than that in NGU. add suf®cient 5% acetic acid to dissolve the phosphate crystals which are responsible for the haze. Microbiological survey of acute epididymitis.69:361±3 Berger R.138:83±6 Hawkins DA.47:1±112 Van Voorst Vader PC. Alternatives to cipro¯oxacin 500 mg are detailed elsewhere22. Taylor-Robinson D. . 75(suppl 1):S51±3 Centers for Disease Control and Prevention. Both the leucocyte esterase dipstick test and the two-glass urine test have reduced sensitivities compared to microscopy for detecting urethritis and are not recommended for the con®rmation of NGU if microscopy is available. et al. threads or ¯ecks. New sexually transmitted diseases treatment guidelines. et al. Stamm WE. Urinary tract infections in sexually active homosexual men. Berger RE. J Infect Dis 1987. This is most likely to indicate a bacterial urinary tract infection but may also represent severe urethritis often due to gonorrhoea or may simply be due to the patient forgetting to void into two glasses and dividing the ®rst glass into two. This has a sensitivity of 490% in experienced hands.155:1341±3 Barnes R. MMWR Morb Mortal Wkly Rep 1998. Ansell J. Epididymitis: aspects concerning etiology and treatment. as detailed for treatment of epididymo-orchitis as secondary to STI. Br J Urol 1988. Sex Trans Inf 1999. et al. The clinical use of epididymal aspiration cultures in the management of selected patients with acute epididymitis. Kessler D. Management This is set out in the ¯ow-chart (Figure 1).95:390±2 . Genitourin Med 1987. Follow-up should take place after 3 days or sooner if there is no improvement. resistant gonococcal infection may be more common as a cause of failure. the haze will persist in the ®rst glass of urine due to the presence of pus cells. Holmes KK. When there is infection of the anterior urethra.soa. Asbach HW. Monda GA. Van den Ende J. If the urine is hazy. Chlamydia trachomatis as a cause of acute `idiopathic' epididymitis. Acute epididymo-orchitis caused by Pseudomonas aeruginosa and treated with cipro¯oxacin. or Positive leucocyte esterase dipstick test on FPU specimen. J Urol 1966.39. Epididymitis: a review of 610 cases. O'Farrell N. . If both glasses are abnormal. Lancet 1986. However.

J Urol 1993. Andriole GL. Teasdale J. Aetiological and therapeutic aspects. Lancet 1994. Int J STD AIDS 2001. I: clinical and microbiological ®ndings (in German) [Abstract].70:187±90 26 Fraser PA. Br J Urol 1995. Ann Surg 1984. Handbook of Genitourinary Medicine.34(suppl 1):111±17 Weidner W. Harper WM IV. Hay PE eds. European guideline for the management of gonorrhoea. Andeson EC. Surgical management of acute bacterial epididymitis with emphasis on epididymotomy. Garbe C. Int J STD AIDS 2001. Garbe C. Siegel BA.128:722±5 Krieger JN. Post-prostatectomy epididymitis. Sex Trans Dis 1984.106:890±1 Weidner W. Vassey LE. Neutrophil enzymes in urine for the detection of urethral infection in men. Genitourin Med 1995. Torsion of the testis and allied conditions. Coker RJ.344:1438 Witherington R. The diagnosis and treatment of the acute scrotum in children and adolescents.12(suppl 3):27±9 Singh G. Urinary tract infections in general practice.12(suppl 3): 30±3 Bignell CJ. A bacteriological and clinical study. European guideline for the management of chlamydial infection. Stern WD. Knowles L. Ultrasound in the assessment of the acute scrotum. Schiefer HG. Eglin R. The intravenous urogram in acute epididymo-orchitis.11:173±81 . Unsatisfactory performance of the leukocyte esterase test of ®rst voided urine for rapid diagnosis of urethritis. Drugs 1987. Ogedegbe AK. acute epididymitis and oseitis pubis. Gan KS. 1999 24 Clinical Effectiveness Group.24:405±21 29 al Mufti RA. Br J Surg 1976. Rekart ML. J Clin Ultrasound 1996. Strohmaier WL.177:177±81 Williamson RCN. Response of acute epididymitis to oxyphenbutazone. The diagnosis and management of urethral discharge in males. Scott SC.71:176±9 27 Benjamin ID. J Urol 1982. UrologeAusgabeA 1999.149:1475±7 31 Middleton WD. The use of Doppler ultrasound in the clinical management of acute testicular pain. Herwig KR. National guideline for the management of non-gonococcal urethritis. European guideline for the management of urethritis. Hamilton Miller JMT.104:143±5 21 Bullock KN. Genitourin Med 1994. orchitis and related conditions. Sloan JB. Lafferty K. Morbidity in male partners of women who have chlamydial infection before termination of pregnancy. In: Barton SE. J Urol 1967. Melson GL. J Urol 1970. Schaerfe CW.200:664±73 Lapides J.12(suppl 3):63±7 23 Horner JP. Blackwell A. Evaluation of the acute scrotum by colourcoded Doppler ultrasonography.75(suppl 1):S9±S12 25 Patrick DM. Taylor DE. Bichler KH. Int J STD AIDS 2001. Radiology 1990.Horner. et al. Bailey RR eds. Epididymitis. Initial therapy of acute unilateral epididymitis using o¯oxacin. Urinary Tract Infections. Sex Trans Inf 1999. Lapides J. Management of epididymo-orchitis and acute scrotal swelling 20 Beck AD. Maclean TA. Lovegrove RH. London: Chapman & Hall Medical.98:528±30 Herwig KR. Oxyphenbutazone therapy for mumps orchitis. Br J Urol 1981. Lacey CJ. London: Arnold. 1998:155±73 28 Herbener TE. Acute scrotal disorders: prospective comparison of 32 33 34 35 36 37 38 39 40 41 42 93 colour Doppler ultrasound and testicular scintography. Weissbach L. Acute non-gonococcal epididymitis. J Urol 1971.76:625±7 30 Wilbert DM. Yates CK. In: Brum®tt W. Correa RJ Jr.63:465±7 Knight PJ.53:47±9 22 Horner PJ.29:272±6 Stary A. Hunt JM.