Acute Scrotal Pain - Suspect Epididymo-orchitis
Gradual onset scrotal pain, swelling, fever
All Pathways
UrologyEmergency
Epididymo-orchitis Management (EAU 2024)
Epididymo-orchitis Management (EAU 2024): Acute Scrotal Pain - Suspect Epididymo-orchitis → ⚠️ FIRST: Rule Out Testicular Torsion → Clinical Assessment ...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Warning ⚠️ FIRST: Rule Out Testicular Torsion
Torsion is surgical emergency - must exclude
- Sudden onset (vs gradual in epididymitis)
- Age: torsion common in adolescents
- Absent cremasteric reflex suggests torsion
- Nausea/vomiting more common with torsion
- If ANY doubt: Doppler US or surgical exploration
- Prehn sign NOT reliable for differentiation
03Action Clinical Assessment
History and examination
- Gradual onset (hours to days)
- Epididymal tenderness (posterior testis)
- Scrotal erythema, swelling, warmth
- Fever, dysuria, urethral discharge
- Sexual history (STI risk assessment)
- Urinary symptoms, recent instrumentation
04Action Doppler Ultrasound
Confirm diagnosis, rule out abscess
- Increased blood flow to epididymis (vs absent in torsion)
- Enlarged, heterogeneous epididymis
- May see reactive hydrocele
- Rule out abscess formation
- Testicular involvement = orchitis
05Decision Likely Pathogen?
Based on age and risk factors
07Action STI Treatment Regimen (EAU 2024)
Cover Chlamydia AND Gonorrhea
- Ceftriaxone 500mg IM x1 dose
- PLUS Doxycycline 100mg PO BID x10-14 days
- Alternative: Azithromycin 1g PO x1 if compliance concern
- Partner notification and treatment
- Test of cure if persistent symptoms
- Screen for HIV, syphilis, hepatitis
08Action Supportive Care
Symptom management
- Scrotal elevation and support
- NSAIDs (ibuprofen 400-600mg TID)
- Ice packs (wrapped, 20 min intervals)
- Rest, avoid strenuous activity
- Hydration
- Sexual abstinence until treatment complete
09Decision Abscess or No Improvement?
After 48-72 hours of treatment
10Action Follow-Up Care
Monitor resolution
- Re-evaluate at 48-72 hours
- Clinical improvement expected
- Complete antibiotic course
- Repeat US if concern for abscess
- Urology referral if recurrent
- Evaluate for structural abnormality
11Outcome Expected Outcomes
Good prognosis with treatment
- Full resolution with appropriate antibiotics
- Swelling may persist for weeks
- Chronic epididymitis in ~15%
- Infertility risk if bilateral/severe
- Recurrence: evaluate for underlying cause
12Action Abscess Management
Surgical consideration
- Percutaneous drainage if accessible
- Surgical drainage/exploration
- Epididymectomy if severe/necrotic
- Orchiectomy if testis non-viable
- IV antibiotics
- Prolonged course
- Path rejoins step 11Shared downstream outcome
14Action Enteric Organism Treatment (EAU 2024)
Fluoroquinolone or TMP-SMX
- Levofloxacin 500mg PO daily x10-14 days
- OR Ciprofloxacin 500mg PO BID x10-14 days
- OR TMP-SMX DS PO BID x10-14 days
- Adjust based on culture results
- Duration: 2-4 weeks for severe cases
- Consider prostate involvement
- Path rejoins step 08Shared downstream outcome
Guideline Source
EAU Guidelines on Urological Infections 2024
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Must rule out testicular torsion if any doubt
- Does not address tuberculous epididymitis in detail
- Pediatric epididymitis may have viral etiology
- Chronic epididymitis requires different approach
- Local antibiotic resistance patterns should guide therapy
Applicable Regions
USEUUKAU
AU: Australian STI guidelines concordant
EU: EAU 2024 - primary European guideline
UK: BASHH guidelines for STI-related, similar to EAU
US: CDC STI guidelines concordant with EAU for STI-related cases
Version 1Next review: 2028-01-11
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Related Resources
Frequently Asked Questions
What is the Epididymo-orchitis Management (EAU 2024)?
The Epididymo-orchitis Management (EAU 2024) is a emergency clinical algorithm for Urology. It provides a structured decision tree to guide clinical decision-making, based on EAU Guidelines on Urological Infections 2024.
What guideline is the Epididymo-orchitis Management (EAU 2024) based on?
This algorithm is based on EAU Guidelines on Urological Infections 2024 (DOI: 10.1016/j.eururo.2024.03.035).
What are the limitations of the Epididymo-orchitis Management (EAU 2024)?
Known limitations include: Must rule out testicular torsion if any doubt; Does not address tuberculous epididymitis in detail; Pediatric epididymitis may have viral etiology; Chronic epididymitis requires different approach; Local antibiotic resistance patterns should guide therapy. Individual patient factors may require deviation from these recommendations.
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