Orchitis is defined as the inflammation of the testicle unilaterally or bilaterally usually caused by viruses and bacteria. Testes are two oval male reproductive organs situated in the scrotum. They are responsible for the production of male sex hormones and sperm. The testis is innervated by testicular plexus, which contains nerves originating from renal and aortic plexus. The main arterial supply is by paired testicular artery, arising from the abdominal aorta, which passes via the inguinal canal inside the spermatic cord. Venous drainage is through pampiniform plexus. As testis are originally retroperitoneal organs, lymphatic drainage is through para-aortic lymph nodes, while superficial inguinal lymph nodes drain the scrotum.
Orchitis can be acute and symptomatic on the presentation or asymptomatic and chronic. Isolated orchitis is rare and usually accompanied by an infection of the epididymis. The major route for the spread is blood-borne dissemination for isolated orchitis. Ascending infections can also involve testis.
Various bacteria and viruses cause orchitis.
There are also reports of orchitis caused by autoimmunity, which can classify as primary and secondary.
Orchitis alone is very uncommon and is usually accompanied by epididymitis, hence the true incidence is unclear. Current literature also does not suggest any predilection for any race or religion.
Orchitis develops in 14% to 35% postpubertal patients with mumps. Symptoms develop 4 to 8 days after parotitis but can also occur in the absence of parotitis. Mumps virus is responsible for most of the cases of isolated orchitis.
Orchitis is the inflammation of testis, and isolated acute orchitis is a very rare phenomenon. Orchitis is usually unilateral, and symptoms can vary from mild to severe. Most cases resolve by the end of two weeks. There are two significant differences between orchitis and infections of other male accessory sex organs
Common risk factors include a preexisting history of epididymitis, unprotected sexual contact, multiple sexual partners, long term use of foley catheter, bladder outlet obstruction, structural abnormality, and lack of immunization with MMR vaccination (vaccination reduces the risk of developing orchitis after Mumps).
The patient usually presents with acute onset of testicular pain, which may initially involve one testis, and then may spread to include the whole scrotum. The patient may also complain of fever accompanied by malaise, fatigue, and chills.
Examination findings may include testicular enlargement, tenderness, and induration. Scrotal edema and erythema may also be present. Epididymis may also be enlarged if orchitis is accompanied with epididymitis. Cremasteric reflex is normal in affected individuals. Mumps orchitis may present with bilateral parotid enlargement and usually present 4 to 8 days after onset of parotitis.
When evaluating such patients, the clinician should also note various risk factors so that they can receive appropriate management.
Orchitis diagnosis is usually from history and physical findings. Laboratory tests are generally not helpful, but urethral swabs and urine samples may be obtained for routine examination and cultures to rule out urinary tract infection and diagnose sexually transmitted infections as the source.
When assessing patients with acute testicular or scrotal pain, it is imperative to rule out testicular torsion. For such patients, Color Doppler ultrasonography of scrotum is the first choice of investigation.
Ultrasonography findings in patients with mumps orchitis usually subside by the seventh day. Although not typically done, serum immunofluorescence antibody testing is useful to confirm the diagnosis of mumps orchitis.
In an emergency, physicians must distinguish between torsion and inflammation of the testis. Antibiotics are not necessary for viral causes of the disease, supportive therapies such as bed rest, antipyretics, analgesics, scrotal support, and hot or cold packs for analgesia are advisable.
Antibiotics should start empirically based on the likely pathogens according to age and sexual history.
Sexual partners of the patient with sexually transmitted pathogens should receive treatment. The inability to take oral antibiotics, signs of sepsis and failure of previous outpatient therapy should warrant inpatient therapy.
Careful evaluation for probable reasons for acute scrotal pain and swelling is essential for the efficient management of the patients. Testicular torsion is the most significant differential as urgent exploration is required. Other differentials include:
Overall, the majority of viral cases and antibiotic-treated cases will resolve without any complications. Most of the patients are treated as outpatients. The swelling and tenderness may persist even after antibiotic therapy but should be significantly improved. In case of persistence, compliance should be checked, and receive further evaluation if required. The decrease in body temperature in the first three days of antibacterial treatment is considered as a good prognostic marker. Most cases of mumps orchitis also resolve within ten days.
Complications are preventable with accurate diagnosis and efficient management of patients. Most patients recover without sequelae; however, there are reports of the following complications:
Rarely in cases of pyogenic orchitis and testicular infarction, an abscess can be formed which require surgical consultation for management.
The majority of cases do not require consultations. In some complicated cases, consultations may be required such as
Prevention revolves primarily in avoiding the risk factors:
All clinical staff should advise patients to take the full course of antibiotics to prevent the emergence of resistance and recurrence.
The management of orchitis is usually on an outpatient basis; severe complications are rare. The condition still merits the involvement of an interprofessional healthcare team. However, several measures can help improve the outcomes and prevent the disease.
A study conducted in England and Wales concluded that vaccination with MMR provides significantly greater protection against hospitalization and risk of orchitis in diagnosed cases of mumps. So parents should be educated about the benefits of getting their children vaccinated.
Another study showed that in general practice, patients presenting with symptoms of orchitis do not usually receive testing for sexually transmitted infections. This practice needs to improve as these infections affect not only the individual but also their sexual partners.
In Europe and the U.S.A, the isolates of Escherichia coli are becoming increasingly resistant to ciprofloxacin, which requires finding alternatives with sufficient penetration into testis for efficient and comprehensive management of orchitis.
Urodynamic studies should only be for patients with suspicion of urinary tract obstruction.
Urology nurses are involved in the administration of treatment, patient education, and reporting back to the team. Pharmacists check medication dosage, interactions, assist the clinician with antimicrobial therapy selection, and also provide patient education. These types of interprofessional team collaboration can improve patient outcomes in cases of orchitis. [Level 5]
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