Patient will present as → a 31-year-old male complaining of unilateral scrotal swelling with pain radiating to the ipsilateral groin. Examination reveals a tender swollen testicle, scrotal edema with erythema, and shininess of the overlying skin.
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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.
Urinalysis with cultures will show pyuria and bacteriuria with cultures positive for suspected organisms
- Color Doppler ultrasonography to rule out other causes of acute scrotum (i.e. testicular torsion)
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)
Question 1 |
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 2 |
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 3 |
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 4 |
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. |
List |
References: Merck Manual · UpToDate