LecturePatient will present as → a 14-year-old male who is brought to the clinic for the sudden onset of right-sided scrotal pain and significant swelling that began this morning. His mother mentions that he recovered from a fever and painful swelling under his jaw about five days ago. On physical examination, the right testicle is enlarged, firm, and exquisitely tender to palpation. The overlying scrotum is warm and erythematous with shininess of the overlying skin. The cremasteric reflex is present, and there is no relief of pain with scrotal elevation (negative Prehn's sign). His immunization records are unavailable.
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Orchitis is an infection of the testes caused by ascending bacterial infection from the urinary tract
- Mumps is a common cause in kids
- Orchitis develops in 20 to 25% of males with mumps; 80% of cases occur in patients less than 10 years old
- Orchitis without epididymitis is very uncommon in adults
Testicular torsion should be ruled out in all cases of new-onset testicular pain
Diagnosed clinically
- Confirm with scrotal ultrasound with Doppler (↑ blood flow) to rule out torsion (torsion = ↓ flow)
- UA/NAAT testing for GC/CT if STI suspected; urine culture if older patient or urinary source suspected
- Consider viral testing if mumps is suspected
Treat with bed rest, NSAIDS, scrotal support, ice, and antibiotics (if bacterial)
Age <35 or sexually active postpubertal males (cover for GC/Chlamydia) - treat like epididymitis
- Ceftriaxone 500 mg IM once PLUS doxycycline 100 mg PO BID for 10 days
- Azithromycin 2 g PO once PLUS doxycycline 100 mg BID if severe PCN allergy
Age >35 (STI not suspected) - Levofloxacin 500 mg/d PO once daily for 10 days (21 days if associated prostatitis)
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Question 1 |
Which of the following is a recognized risk factor for the development of orchitis?
High dietary calcium intake Hint: There is no direct link between dietary calcium intake and an increased risk of orchitis. | |
History of mumps infection | |
Frequent bicycling Hint: While it can cause trauma or discomfort to the testicles, it's not a direct risk factor for orchitis. | |
Use of anabolic steroids Hint: Associated with testicular atrophy and other reproductive issues, but not directly with orchitis. | |
Low body mass index (BMI) Hint: Not associated with an increased risk of orchitis. |
Question 1 Explanation:
Orchitis develops in 20 to 25% of males with mumps; 80% of cases occur in patients less than 10 years old. Mumps virus can spread to the testes, leading to inflammation and swelling, a condition known as mumps orchitis, which is the most common cause of viral orchitis.
Question 2 |
A 25-year-old man presents with acute onset of testicular pain, swelling, and a fever of 38.5°C (101.3°F). Physical examination reveals a swollen, tender testis with a normal cremasteric reflex. Which of the following is the most appropriate initial diagnostic test?
Testicular ultrasound with Doppler | |
MRI of the pelvis Hint: Not the first-line imaging modality for acute testicular conditions. | |
Urinalysis Hint: Useful for diagnosing urinary tract infections, which can be associated with or lead to epididymo-orchitis, but not definitive for orchitis. | |
Gonorrhea and chlamydia testing Hint: Gonorrhea/chlamydia testing may be done to evaluate for infectious etiologies but ultrasound should come first. | |
Complete blood count (CBC) Hint: Can indicate infection but is not specific for diagnosing orchitis. |
Question 2 Explanation:
Testicular ultrasound with Doppler is the most appropriate initial diagnostic test for a patient presenting with symptoms suggestive of orchitis. It can help differentiate orchitis from other causes of acute scrotal pain which cannot be missed, such as testicular torsion, by assessing blood flow and the presence of inflammation in the testis.
Question 3 |
A 32-year-old man presents with acute onset of left testicular pain and swelling. He is sexually active, although his last sexual encounter was over nine months ago, and he reports always using condoms. Scrotal ultrasound shows an enlarged heterogeneous left testis with increased blood flow. Urinalysis shows WBCs, and urine culture is pending. You have sent the urine for GC/Chlamydia testing. Which of the following is the most appropriate management at this time?
Immediate surgical exploration Hint: Surgical exploration is not the first-line management for acute testicular pain unless there is a high suspicion of testicular torsion, which is not indicated by the ultrasound findings of increased blood flow (suggesting infection rather than ischemia). | |
Empiric treatment with intramuscular ceftriaxone and oral doxycycline | |
Await urine culture and GC/Chlamydia test results before initiating treatment Hint: Delaying treatment in the setting of suspected epididymitis or orchitis can lead to complications. Empiric antibiotic therapy should be started promptly based on the clinical presentation and risk factors. | |
Oral levofloxacin monotherapy Hint: While levofloxacin is an effective treatment for urinary tract infections and can cover some causes of epididymitis or orchitis, the recommended empiric therapy for sexually transmitted infections includes coverage for both gonorrhea and chlamydia, best achieved with the combination of ceftriaxone and doxycycline. | |
Supportive care with scrotal elevation and NSAIDs only Hint: While supportive care is an important adjunctive treatment, it is not sufficient as the sole management for suspected infectious epididymitis or orchitis. Antibiotic therapy is necessary to address the underlying infection. |
Question 3 Explanation:
Given the patient's presentation with acute testicular pain, swelling, and findings suggestive of infection (increased blood flow on ultrasound, pyuria on urinalysis), along with a sexually active history, empiric treatment for suspected epididymitis or orchitis is warranted. The recommended empiric therapy targets the most common causes, including Neisseria gonorrhoeae and Chlamydia trachomatis, with intramuscular ceftriaxone (a broad-spectrum cephalosporin effective against gonorrhea) and oral doxycycline (effective against Chlamydia). This approach is appropriate while awaiting specific test results, as delaying treatment can lead to complications such as abscess formation or infertility.
Question 4 |
A 12-year-old boy comes to the clinic with pain and swelling in his left testicle. He experienced a fever, loss of appetite, and swelling and tenderness near his ears two weeks prior, which improved after three days. Based on his presentation, what is the most appropriate management approach?
Prescribe antibiotics targeting Gram-negative bacteria Hint: Bacterial orchitis occurs more commonly in older men and is treated the same as epididymitis | |
Perform a fine needle aspiration to analyze scrotal fluid Hint: Conducting a testicular ultrasound is a reasonable step if there is uncertainty about the diagnosis or to rule out other causes of testicular swelling, such as a tumor or torsion, but the clinical history strongly suggests a viral process. | |
Recommend ice packs and pain relief medication | |
Conduct a testicular ultrasound to exclude the presence of a tumor Hint: If a testicular mass or torsion is suspect, ultrasonography and urgent referral are recommended. | |
Arrange a consultation with a urologist for a detailed evaluation Hint: If a testicular mass or torsion is suspect, ultrasonography and urgent referral are recommended. |
Question 4 Explanation:
The most common cause of orchitis in prepubescent males is mumps. Treatment is ice and analgesics, such as acetaminophen. Bacterial orchitis occurs more commonly in older men and is treated the same as epididymitis. If a testicular mass or torsion is suspect, ultrasonography and urgent referral are recommended.
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References: Merck Manual · UpToDate