Acute Epididymo-orchitis

Comments from expert advisory group:

  1. Acute epididymo-orchitis is a clinical syndrome consisting of pain, swelling and inflammation of the epididymis +/- testes usually caused by local extension of infection from the urethra (sexually transmitted) or the bladder (urinary)
  2. In men under 35 years it is more often a sexually transmitted infection (eg chlamydia or gonorrhoeae. In men over 35 years it is more often a non-sexually transmitted gram negative enteric organism causing urinary tract infections.  A sexual history should be taken to determine risk of STIs. Mumps and TB can cause epididymo-orchitis
  3. MSM who engage in insertive anal intercourse are at risk of epididymo-orchitis secondary to sexually transmitted enteric organisms
  4. All patients with urinary tract pathogen confirmed epididymo-orchitis should have further investigations of the urinary tract as anatomical or functional abnormalities are more common in this group.
  5. Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling of relatively acute onset. There may be symptoms of urethritis or a UTI depending on the causative organism.
  6. Testicular torsion is the most important differential diagnosis. It is a surgical emergency. It should be considered in all patients, is more likely in younger patients and the onset of severe pain is usually short (four hours).
  7. All patients presenting with symptoms and signs of epididymo-orchitis should be offered testing for chlamydia and gonorrhoea and have a mid-stream urine sent for culture and sensitivity.
  8. Individuals diagnosed with an STI should be offered testing for other STIs including HIV, Hepatitis B, syphilis chlamydia and gonorrhoea.
  9. HCV testing should be considered part of routine sexual health screening in the following circumstances: People who are HIV positive; Commercial sex workers; PWID; If indicated by the clinical history e.g. unexplained jaundice; When other risk factors for HCV are present, for example MSM. The full set of recommendations around HCV testing are available in the national HCV screening guidelines
  10. Individuals diagnosed with epididymo-orchitis should be advised to abstain from sexual intercourse until treatment completed and where indicated their partner has been treated. Where chlamydia or gonorrhoea are diagnosed, partner notification should be undertaken as per recommendations for those infections.
  11. Where chlamydia or gonorrhoea have been diagnosed in patients with epididymo-orchitis, these infections should be notified. The complete list of notifiable diseases and information on the notification process is available

Treatment options:

  • Rest, analgesia (for example non-steroidal anti inflammatory drugs where not contraindicated) are recommended.
  • Empirical antimicrobial therapy should be given to all patients with epididymo-orchitis before culture/NAAT results are available. The antibiotic regimen chosen should be determined by age, sexual history, recent urinary tract instrumentation, other symptoms and where available initial test results (urethral smear, urinanalysis, urine microscopy)
  • Follow-up is recommended within 3 days if symptoms don’t settle with empiric treatment

acute epididymo orchitis treatment table 2019 image

Useful resources:

Patient information:

Reviewed May 2019