Epididymo-orchitis Management (EAU 2024)

Algorithm Steps

1. ▶

   Start

   Acute Scrotal Pain - Suspect Epididymo-orchitis

   Gradual onset scrotal pain, swelling, fever

   1. ⚠

      Warning

      ⚠️ 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
      1. ●

         Action

         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
         1. ●

            Action

            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
            1. ◆

               Decision

               Likely Pathogen?

               Based on age and risk factors

               1. ●

                  Action

                  STI-Related (Age <35, Sexual Risk)

                  Chlamydia, Gonorrhea most common

                  • Sexually active men <35 years
                  • Urethral discharge present
                  • Recent new partner
                  • NAAT for Chlamydia/Gonorrhea
                  • Urethral swab if discharge
                  • Test/treat partner
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                        1. ◆

                           Decision

                           Abscess or No Improvement?

                           After 48-72 hours of treatment

                           1. ●

                              Action

                              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
                              1. ✓

                                 Outcome

                                 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
                           2. ●

                              Action

                              Abscess Management

                              Surgical consideration

                              • Percutaneous drainage if accessible
                              • Surgical drainage/exploration
                              • Epididymectomy if severe/necrotic
                              • Orchiectomy if testis non-viable
                              • IV antibiotics
                              • Prolonged course
               2. ●

                  Action

                  Enteric Organisms (Age >35, No STI Risk)

                  E. coli, Pseudomonas, Enterococci

                  • Older men (>35 typically)
                  • Associated UTI symptoms
                  • Recent urinary instrumentation
                  • BPH with obstruction
                  • Urine culture and sensitivity
                  • Consider structural evaluation
                  1. ●

                     Action

                     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