1. No category

IUSTI EO Guideline 2012v1 1.8.2012
2012 European guideline on the management of epididymo-orchitis
Authors:
Street EJ1, Portman MD2, Kopa Z3, Brendish NJ4, Skerlev M5, Wilson JD2, Patel R6
1. Calderdale and Huddersfield NHS Foundation Trust, UK
2. Leeds General Infirmary, UK
3. Semmelweis University, Hungary
4. Southampton General Hospital, UK
5. University of Zagreb, Croatia
6. University of Southampton, UK
Revision date: 1 August 2013
Proposed date for review: 1 August 2016
Appendix 1 is the authors’ declarations of interests
Appendix 2 lists the full membership of the IUSTI Guidelines Editorial Board (2012)
Appendix 3 details levels and grading of evidence
IUSTI EO Guideline 2012v1 1.8.2012
AETIOLOGY AND TRANSMISSION
Epididymo-orchitis is an inflammatory process of the epididymis +/- testes1. This clinical
syndrome most often presents with acute onset of pain and swelling. It is caused by either
sexually transmitted pathogens ascending from the urethra or non-sexually transmitted
uropathogens spreading from the urinary tract.
Sexually transmitted infections
Chlamydia trachomatis- predominantly in the young2
Neisseria gonorrhoeae- predominantly in the young2
Gram negative enteric organisms – in men engaging in insertive anal intercourse2
Non- sexually transmitted infections
Gram negative enteric organisms- risk factors include obstructive urinary disease, urinary
tract surgery or instrumentation3.
Mumps (commonest cause of isolated orchitis) - may occur as part of an epidemic, more
frequently in an area with insufficient vaccination programme 4
Tuberculosis - commonly associated with renal TB, but can also be an isolated finding 5
Brucellosis 6
Candida
Non-infectious
Amiodarone - symptoms usually resolve on cessation of treatment 7
Behcet's disease - associated with more severe disease, occurring in 12-19% of men with
Behcet’s disease. 8
CLINICAL FEATURES
 symptoms: acute onset, usually unilateral scrotal pain +/- swelling 9
 symptoms of urethritis- urethral discharge, dysuria, penile irritation but
patients can be asymptomatic 10,11,12
 symptoms of urinary tract infection – dysuria, frequency, urgency
 physical signs: typically unilateral swelling and tenderness of epididymis +/- testes,
usually beginning in the tail of the epididymis and spreading to involve the whole of
the epididymis and testes.
 Other signs:
IUSTI EO Guideline 2012v1 1.8.2012
◦ urethral discharge
◦ hydrocoele
◦ erythema +/- oedema of scrotum
◦ pyrexia
Disease specific symptoms and signs:
Mumps: headache and fever followed by uni/bilateral parotid swelling followed 7-10
days later by unilateral testicular swelling. Atypically, those affected can present
with bilateral testicular swelling, epididymitis alone or without systemic
symptoms13,14
Tuberculosis: subacute/more chronic onset of painless/ painful scrotal swelling +/systemic symptoms +/- scrotal sinus +/- thickened scrotal skin 15,16
Brucellosis: fever, sweats, headache, back pain, and weakness in acute infection. 17
Complications:
These tend to be more frequently seen with uropathogen-associated infection 18.
◦ hydrocoele
◦ abscess and infarction of the testicle
◦ infertility -It is not known if epididymo-orchitis increases the risk of
infertility
DIAGNOSIS
Epididymo-orchitis is a clinical diagnosis based on symptoms and signs.
The history, eliciting genitourinary symptoms and the risk of STIs (including anal
intercourse), alongside examination findings and preliminary investigations will suggest the
most likely aetiology and guide empiric antibiotics.
Differential diagnosis
Testicular torsion is the main differential diagnosis. This is a surgical emergency.
If a young man or adolescent presents with a painful swollen testicle of sudden onset then
the diagnosis is testicular torsion until proven otherwise 19. The patient should be promptly
referred to urologist. Testicular salvage is required within six hours and the likelihood of a
good outcome decreases with time 20,21. Empiric antibiotics should also be issued in these
circumstances.
IUSTI EO Guideline 2012v1 1.8.2012
Torsion is more likely if
 patient is under 20 years (but can occur at any age)
 the pain is sudden (within hours)
 the pain is severe
 preliminary tests do not show urethritis or likely urinary tract infection (UTI) 20,21.
A colour Doppler ultrasound (duplex) may be helpful in assessing the vascularity of the
testes and therefore may aid in differentiating between epididymo-orchitis and testicular
torsion.22,23 Arranging an ultrasound should not delay surgical exploration.
Preliminary investigations should include
 diagnosis of urethritis with microscopy of a Gram stained24/ methylene blue stained
25,26
urethral smear showing > 5 polymorphonuclear leucocyte (PMNL) per High
Power Field (HPF) (1000x) OR a spun down sample from first pass urine Gram
stained showing >10 PMNLs per HPF (1000x).
 urine dipstick – useful only as an adjunct to mid-stream specimen of urine (MSU) 27.
A negative dipstick test in men should not exclude the diagnosis of UTI. 28,29 The
presence of nitrite and leukocyte-esterase suggests UTI in men with urinary
symptoms. 28,29
Laboratory investigations
•
Urethral swab for N. gonorrhoeae culture
•
First pass urine (FPU)/ urethral swab for nucleic acid amplification test (NAAT) for
N. gonorrhoeae and C. trachomatis
•
Mid-stream specimen of urine for microscopy and culture
•
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can aid the
diagnosis of epididymitis if raised, but surgical referral or antibiotic treatment should
not be delayed on the basis of these tests30,31
All patients with sexually transmitted epididymo-orchitis should be screened for other
sexually transmitted infections including blood borne viruses.
IUSTI EO Guideline 2012v1 1.8.2012
MANAGEMENT
 Information, explanation and advice should be given to the patient: an explanation
of the causes of epididymo-orchitis (both sexually transmitted and non-sexually
transmitted), the short term course of the infection and the long term implications for
themselves and their partner (if sexually transmitted cause).
 General advice- analgesia, rest and scrotal support.
 Sexual abstinence should be advised for those with suspected sexually transmitted
epididymo-orchitis until treatment is completed by both patient and partner and their
symptoms have settled2.
 Therapy- empiric antibiotics according to the likelihood of a sexually transmitted or
uropathogen.
 Choose regime based on immediate tests- urethral/fpu smear, urinalysis. Take into
account age, sexual history, recent surgery/ catheterisation, any known urinary tract
abnormalities, the local prevalence of gonorrhoea and antibiotic resistance patterns.
Sexually transmitted epididymo-orchitis –
First line choice
Ceftriaxone 500mg intramuscular injection 32IIIB PLUS
Doxycycline 100mg bd for 10 to 14 days 33,34 IIIB
OR
Second line choice
Ofloxacin 200mg bd for 14 days 33,34 IIB or levofloxacin 500mg od for 10 days IIIB 35
Epididymo-orchitis most likely secondary to enteric organisms
Ofloxacin 200mg bd for 14 days 36,37,38 IIB
OR
Ciprofloxacin 500mg bd for 10 days39 IA
Points to note and consider
1. Where gonorrhoea is considered unlikely; i.e. urethral /FPU microscopy negative
for gram negative intracellular diplococci (GNID), no risk factors for gonorrhoea
identified (absence of all of the following - a purulent urethral discharge, known
contact of GC, MSM, black ethnicity) 32 and in countries/ populations where there is
IUSTI EO Guideline 2012v1 1.8.2012
known to be a very low gonorrhoea prevalence, omitting cetriaxone or using
ofloxacin could be considered40. Ofloxacin treats N. gonorrhoeae, C. trachomatis
and most uropathogens with good penetration into the prostate. However, it is not
first line treatment for N. gonorrhoeae due to increasing bacterial resistance to
quinolones 41
2. Ciprofloxacin does not effectively treat chlamydia42
3. If epididymitis secondary to gonorrhoea is confirmed, a test of cure is required 2
weeks after completing gonorrhoea treatment using a NAAT or after 3 days
following completion of gonorrhoea treatment with a positive gonorrhoea culture,
particularly if treatment has been with a quinolone 41.
Partner notification
For patients with confirmed or suspected sexually transmitted epididymo-orchitis ( N
gonorrhoeae or C. trachomatis) all partners potentially at risk should be notified and
evaluated. They should be tested for other STIs and given treatment with antibiotics to
cover C. trachomatis (and N. gonorrhoeae if confirmed in the index patient). The duration
of look back is arbitrary, as the incubation period for epididymo-orchitis is unknown. Sixty
days is suggested on the basis of current gonorrhoea and chlamydia guidelines 43,44.
Follow up
-
At 3 days if no improvement in symptoms, the patient should be seen for clinical
review and the diagnosis should be re-assessed.
-
At 2 weeks for compliance check, assessment of symptoms, repeat NAAT and
partner notification. This could be done by telephone but if the patient has
persisting symptoms, arrangements should be made for clinical review.
Further investigations
All patients with suspected/ confirmed sexually transmitted epididymo-orchitis should be
screened for other STIs including blood borne viruses.
All patients with uropathogen confirmed epididymo-orchitis should be referred to a urology
specialist for further investigations looking for structural abnormalities / urinary tract
obstruction 45.
In patients where there has not been significant improvement in symptoms/signs after
completion of therapy or there is diagnostic doubt, a scrotal ultrasound should be ordered.
IUSTI EO Guideline 2012v1 1.8.2012
Differential diagnoses to consider in these circumstances include progression to
abscess46, testicular ischaemia/ infarct47 and testicular/ epididymal tumour48. Further
referral onto urology should also be considered.
Prevention/health promotion
Patients should be advised that consistent condom use will reduce the risk of acquiring
sexually transmitted infections including epididymo-orchitis49.
SEARCH STRATEGY
The guideline for management of epididymo-orchitis was written after a literature
search in the Medline, Embase, and Cochrane databases for English-language articles
published between 2001 and March 2012. Current major European National and CDC
guidelines were also reviewed.
The authors would like to thank those who have kindly commented on the production of
this guideline, including:
Dr W I van der Meijden
Dr K Radcliffe
Prof J Ross
Dr J Sherrard
This guideline has been produced on behalf of the following organisations: the European
Branch of the International Union against Sexually Transmitted Infections (IUSTI Europe);
the European Academy of Dermatology and Venereology (EADV); the European
Dermatology Forum (EDF); the Union of European Medical Specialists (UEMS). The
European Centre for Disease Prevention and Control (ECDC) and the European Office of
the World Health Organisation (WHO-Europe) also contributed to its development.
IUSTI EO Guideline 2012v1 1.8.2012
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4. Gupta RK, Best J and MacMahon E. Mumps and the UK epidemic 2005. BMJ
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5. Viswaroop BS, Kekre N, Goplalkrishnan G. Isolated tuberculous epididymitis:a
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8. Cho YH, Jung J, Lee KH, Bang D, Lee ES and Lee S. Clinical features of patients
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9. Giesler WM and Krieger JN. Epididymitis In Sexually Transmitted Diseases. Holmes
KK, Sparling PF, Stamm WE, et al.. 4th Edition 2008. McGraw Hill Medical, 2008:11271146
10. Hawkins DA, Taylor-Robinson D, Thomas BJ, et al. Microbiological survey of acute
epididymitis. Genitourin Med 1986;62:342-4.
11.Mulcahy FM, Bignell CJ, Rajakumar R, et al. Prevalence of chlamydial infection in
acute epididymo-orchitis. Genitourin Med 1987;63:16-18
12. Watson RA. Gonorrhoea and acute epididymitis. Mil Med 1979;144:785-787
13. Wharton IP, Chaudhry AH and French ME. A case of mumps epididymitis. Lancet
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14. Nickel WR, Plumb RT. Mumps orchitis. In Harrison JH, Gittes RF, Perlmutter AD,
Stamey TA, Walsh PC, eds. Campbells Urology, 5th edn. Philadelphia:W.B. Saunders
Co., 1986:977-988.
15. Viswaroop BS, Kekre N, Goplalkrishnan G. Isolated tuberculous epididymitis:a
review of 40 cases. J Postgrad Med 2005;51(2):109-111.
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16. Ferrie BG, Rundle JS. Tuberculous epididymo-orchitis: a review of 20 cases. Br J
Urol 1983;55:437-439.
17. Maloney GE; Brucellosis, eMedicine, Apr 2009
18. Luzzi GA and O’Brien TS. Acute epididymitis. BJU Int 2001;87:747-755
19. Dudley M. Assume nothing. MPS casebook 2007;15(3):23.
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20.. Williamson RCN. Torsion of the testis and allied conditions. Br J Surg
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21.Knight PJ, Vassey LE. The diagnosis and treatment of the acute scrotum in
children and adolescents. Ann Surg 1984;200:664-73
22.Rizvi SAA, Ahmed I, Siddiqui MA,et al. Role of colour doppler ultrasonography in
evaluation of scrotal swellings: pattern of disease in 120 patients with review of
literature. Urol J 2011;8(1):6065.
23.Dell’Atti L, Fabiani A, Marconi A, et al. Reliability of echo-colour-doppler in the
differential diagnosis of the “acute scrotum”- our experience. Arch Ital Urol Androl
2005;77:66-68.
24. Swartz SL, Kraus SJ, Herrmann KL, Stargel MD, Brown WJ, Allen SD. Diagnosis
and etiology of nongonococcal urethritis. JID 1978;138(4):445-454
25.Falk L, Fredlund H, Jensen JS. Symptomatic urethritis is more prevalent in men
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26. Moi H, Danielsson D. Diagnosis of genital Chlamydia trachomatis infection in males
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27. Schmiemann G, Kniehl E, Gebhardt K, et al.The Diagnosis of Urinary Tract
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28. Koeijers JJ, Kessels AG, Nys S, et al. Evaluation of the nitrite and leukocyte
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29. Etienne M, Pestel-Caron M, Chavanet P, Caron F.Performance of the urine
leukocyte esterase and nitrite dipstick test for the diagnosis of acute prostatitis.
Clin Infect Dis. 2008 Mar 15;46(6):951-3.
30. Cifci AO, Senocak ME, Tanyel FC, et al. Clinical predictors for differential diagnosis
of acute scrotum. Eur J Paediat Surg 2004;14(5):333-338.
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31.Durehn C, Fornara P, Buttenr H, et al. Value of acute phase proteins in the
differential diagnosis of acute scrotum. Eur Urol 2001;39(2):215-221.
32. Street E, Joyce A and WilsonJ.BASHH UK guideline for the management of
epididymo-orchitis, 2010. Int J STD AIDS 2011; 22 (7):361-365.
33. Berger RE, Alexander ER, Harnisch JP, et al. Etiology, manifestations and therapy
of acute epididymitis: prospective study of 50 patients. J Urol 1979;121:750-4.
34. Hoosen AA, O'Farrell N, Van den Ende J. Microbiology of acute epididymitis in a
developing country. Genitourin Med 1993;69:361-3.
35. Santo I, Suzuki A, Saiko Y,et al. Acute nongonoccal epididymitis :pharmacological
and therapeutic aspects of levofloxacin. Hinyukika Kiyo 1992:38(5):623-628.
36. Melekos MD, Asbach HW. Epididymitis: aspects concerning etiology and
treatment. J Urol 1987;138:83-6.
37. Weidner W, Schiefer HG, Garbe C. Acute non-gonococcal epididymitis.
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38.Weidner W, Garbe C, Weissbach L, et al. Initial therapy of acute unilateral
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39. Eickhoff JH, Frimodt-Moller N, Walters S, 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;84:827-34.
40. O’Mahony C and Evans-Jones J. Re- urological management of epididymo-orchitis,
simple, ofloxacin for all. STI 2011;87:143.
41. Bignell C and Fitzgerald M. UK National guidelines for the management of
gonorrhoea in adults,2011. Int J STD and AIDS 2011;22:541-547.
.42.Hooton TM, Rogers ME, Medina TG, Kuwamura LE, Ewers C, Roberts PL, Stamm
WE..Ciprofloxacin compared with doxycycline for nongonococcal urethritis.
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43.Bignell C. 2009 European (IUSTI/WHO) Guideline on the Diagnosis and Treatment
of Gonorrhoea in Adults. Int J STD and AIDS 2009;20:453-457.
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46. Desai KM, Gingell JC, Haworth JM.Localised intratesticular abscess complicating
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47. Rencken RK, du Plesses DJ, de Haas LS, et al. Venous infarction of the testis – a
cause of non-response to conservative therapy in epididymo-orchitis. A case report. S
Afr Med J 1990;78:337-338.
48. Giesler WM and Krieger JN. Epididymitis In Sexually Transmitted Diseases.
Holmes KK, Sparling PF, Stamm WE, et al.. 4th Edition 2008. McGraw Hill Medical,
2008:1127-1146.
49. National Institutes of Health. Workshop Summary: Scientific evidence on condom
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Human Services, 2001.
IUSTI EO Guideline 2012v1 1.8.2012
Appendix 1.
Declarations of interest: None of the authors or editors had any conflicts of interest for the
content of this guideline
IUSTI EO Guideline 2012v1 1.8.2012
Appendix 2.
European STI Guidelines Editorial Board
Dr Keith Radcliffe, UK – Editor-in-Chief
Dr Karen Babayan, Armenia (appointed 2009)
Dr Marco Cusini, Italy (app. 2010)
Prof Mikhail Gomberg, Russia (app. 2010)
Dr Michel Janier, France (app. 2006)
Dr Jorgen Skov Jensen, Denmark (app. 2006)
Prof Harald Moi, Norway (app. 2007)
Dr Raj Patel, UK (app. 2006)
Prof Jonathan Ross, UK (app. 2006)
Dr Jackie Sherrard, UK (app. 2009)
Dr Magnus Unemo, Sweden (app. 2009)
Dr Willem van der Meijden, Netherlands (app. 2006)
Dr Simon Barton (UK) – UEMS representative, UK (app. 2010)
Dr Lali Khotenashvili – WHO European Office representative, Georgia (app. 2007)
Dr Marita van de Laar – ECDC representative, Netherlands (app. 2007)
Prof Martino Neumann - EDF representative, Netherlands (app. 2006)
Prof George-Sorin Tiplica, - EADV representative, Romania (app. 2012)
- EDF representative (app. 2012)
IUSTI EO Guideline 2012v1 1.8.2012
Appendix 3.
Levels of Evidence.
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well designed study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental
study.
III Evidence obtained from well-designed non-experimental descriptive studies such as
comparative studies, correlation studies, and case control studies.
IV Evidence obtained from expert committee reports or opinions and /or clinical experience
of respected authorities.
Grading of Evidence.
A (Evidence levels Ia, Ib) Requires at least one randomised control trial as part of the
body of literature of overall good quality and consistently
addressing the specific recommendation.
B (Evidence IIa, IIb, III) Requires availability of well conducted clinical studies but no
randomised clinical trials on the topic of recommendation.
C (Evidence IV) Requires evidence from expert committee reports or opinions
and/or clinical experience of respected authorities. Indicates absence of directly applicable
studies of good quality.