James B. Angel, MD
Stephen E. Strup, MD, FACS
BASICS
DESCRIPTION
• Inflammatory reaction of the testes secondary to infectious or noninfectious etiology
– Infectious (viral, bacterial, fungal)
– Noninfectious (idiopathic, trauma, autoimmune)
• Can be acute or chronic if present for >6 weeks
• Untreated epididymitis can progress to epididymo-orchitis
EPIDEMIOLOGY
Incidence
• Dramatic decline in incidence following the development MMR vaccine (Measles-Mumps-Rubella)
• 4 out of 5 cases occur in prepubertal males (<10 years old) prior to widespread use of MMR vaccine
• Recent increase in incidence in postpubertal males corresponding to mumps outbreaks following national shortages of MMR vaccine as well as controversy related to MMR vaccine itself1
• Bacterial orchitis even more rare and usually associated with concurrent epididymitis
Prevalence
• ∼20% prepubertal males with mumps develop orchitis
• Recent case reports of postpubertal vaccinated males with mumps developing orchitis in outbreaks2
RISK FACTORS
• Not being vaccinated against mumps virus
• Sexually transmitted diseases (STD) leading to epididmo-orchitis (i.e., Neisseria, Chlamydia, Treponema)
• Epididymitis or benign prostatic hypertrophy, BPH (ie, Escherichia, Klebsiella, Pseudomonas, Staphylococcus, and Streptococcus)
• Fungal infections occasionally (i.e., candidiasis, aspergillosis, histoplasmosis, coccidioidomycosis, blastomycosis, actinomycosis)
• History of intravesical Bacillus Calmette Guerin (BCG) for bladder cancer
• Immunocompromised patients (i.e., Mycobacterium, Tuberculosis, Cryptococcus, Toxoplasma, Haemophilus, Candida)
• Case reports of mumps orchitis after immunization with MMR vaccine
Genetics
• There is no clearly defined genetic predisposition toward or familial disorders commonly associated with most cases of orchitis
• Autoimmune states have been implicated in truly noninfectious orchitis
PATHOPHYSIOLOGY
• Most commonly caused by hematogenous spread of mumps virus directly attacking testicular tissue resulting in parenchymal edema, congestion of seminiferous tubules, and perivascular infiltration of lymphocytes
– Rare case reports of other viruses causing orchitis (mononucleosis, coxsackie virus, others)
• Cases of bacterial orchitis usually result from local spread from the ipsilateral epididymitis
• Truly noninfectious orchitis is usually idiopathic, trauma-related, or possibly autoimmune
• Orchitis is unilateral in 70% of cases
• Contralateral testis involvement can follow in 1–9 days
• Seminiferous tubules can experience necrosis from increased pressure and edema
ASSOCIATED CONDITIONS
• Mumps
• Epididymitis
• STD in sexually active men
• Urinary Tract Infections (UTI) in boys or elderly men
• BPH particularly in men >50
• Bladder cancer and history of intravesical BCG
• Immunocompromised states
GENERAL PREVENTION
• Vaccination against mumps virus limits mumps orchitis
• Protection from STD
• Treatment of epididymitis prior to progression to epididymo-orchitis
DIAGNOSIS
HISTORY
• Testicular pain and swelling
– Mild discomfort to severe pain
– Onset of scrotal pain and edema is acute
• History of recent scrotal trauma
• Systemic symptoms
– Fatigue
– Malaise
– Myalgias
– Fever and chills
– Nausea, emesis
– Headache
• Obtain vaccination history
• Mumps orchitis follows development of parotitis by 4–7 days
• Obtain sexual history as appropriate
• Evidence or history of immunocompromise
• History of BPH
• History of recent instrumentation (ie, catheterization, prostate biopsy, cystoscopy) increases likelihood of epididymo-orchitis
• History of intravesical BCG therapy, may result in granulomatous orchitis
PHYSICAL EXAM
• Testicular exam:
– Unilateral or bilateral involvement
– Enlargement, induration, tenderness common
– Erythema and edema of overlying scrotal skin
– An enlarged epididymis is associated with epididymitis, typically unilateral
– May find concurrent reactive hydrocele which transilluminates
• Rectal exam:
– A soft, boggy prostate, which signifies prostatitis, can be associated with epididymitis
• Other:
– Fever and/or chills
– Urethral discharge
– Abdominal masses or tenderness
– Parotitis
– Urethritis
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and urine culture
• Urethral cultures if concern for urethritis
• Mumps: serum immunofluorescence antibody assay
Imaging
• Trans-scrotal color Doppler Ultrasound is considered required by many clinicians:
– Can rule out testicular torsion or malignancy
• Additional imaging is unnecessary (i.e., CT Scan or MRI)
Diagnostic Procedures/Surgery
Usually not necessary
Pathologic Findings
• With viral infection, destruction of germ cells, edema and extensive inflammatory cell infiltrate is noted
• Later seminiferous tubules can experience necrosis from increased pressure and edema, with subsequent interstitial fibrosis.
DIFFERENTIAL DIAGNOSIS
• Epididymitis
• Granulomatous orchitis, infectious and noninfectious
• Reactive hydrocele
• Scrotal pyocele
• Testicular malakoplakia
• Testicular torsion
• Torsion of testicular appendage
• Testicular tumor
TREATMENT
GENERAL MEASURES
• Supportive in nature
– Bed rest
– Hot or cold packs for analgesia
Applied for 10–15 mins q.i.d or until pain subsides
– Scrotal elevation and support with tight fitting underwear or athletic support Analgesics
– Nonsteroidal anti-inflammatory drugs (NSAID)
– Antiemetics
– Counsel patient on safe sex practices if STD suspected
MEDICATION
First Line
• There are no targeted medications indicated the treatment of viral orchitis. Supportive care is essential.
• Bacterial orchitis requires coverage with appropriate antibiotic for suspected pathogen(1)[C]
– <35 years old, suspected STD as causative agent:
Ceftriaxone 125-250 mg IM once and either doxycycline 100 mg PO b.i.d. for 7 days or azithromycin 1-2 g PO once
– >35 years old, or epididymo-orchitis secondary to UTI:
Additional gram-negative coverage with a fluoroquinolone or trimethoprim-sulfamethoxazole (TMP-SMX)
• Tailor antibiotic prescription to local resistance patterns of most common UTI pathogens
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Surgical intervention is generally not indicated in the treatment of acute or chronic orchitis
• Associated scrotal pyocele or symptomatic hydrocele may require surgery
• Orchidectomy for chronic orchitis refractory to supportive measures is an option, but patients must be counseled surgery may not alleviate pain (2)[B]
• Consider microsurgical denervation of cord for chronic refractory orchitis/orchalgia following favorable response to spermatic cord block (3)[A]
– 10 mL of 0.5% bupivacaine injected to cord for block
ADDITIONAL TREATMENT
Radiation Therapy
There is no role for radiation therapy
Additional Therapies
Interferon-α2B has been investigated in bilateral mumps orchitis, given that the mumps virus replicates with a virion-associated transcriptase
Complementary & Alternative Therapies
Patient specific referral for psychologic evaluation and support for chronic refractory orchitis
ONGOING CARE
PROGNOSIS
• Most cases of mumps orchitis are self-limited, resolving within 3-10 days
• With appropriate antibacterial coverage, most cases of bacterial orchitis resolve without complication
COMPLICATIONS
• Unilateral testicular atrophy in up to 60% with mumps orchitis
• Sterility is rarely a sequel of unilateral orchitis
• Impaired fertility reported rates of 7–13%
• No definitive evidence for increased risk of testicular tumor with history of orchitis
FOLLOW-UP
Patient Monitoring
• Most patients can be safely monitored in an outpatient setting
• A patient with a STD as the cause of orchitis should be tested for other STDs including Human immune deficiency virus (HIV)
Patient Resources
• http://www.mayoclinic.com/health/orchitis
• http://www.urologyhealth.org
REFERENCES
1. Nicholson A, Murray-Thomas T, Hughes G, et al. Management of epididymo-orchitis in primary care: results from a large UK primary care database. Br J Gen Pract 2010;579:407–422.
2. Nariculam J, Minhas S, Adeniyi A, et al. A review of the efficacy of surgical treatment for and pathological changes in patients with chronic scrotal pain. BJU Int 2007;99:1091–1093.
3. Larsen SM, Benson JS, Levine LA. Microdenervation of the spermatic cord for chronic scrotal content pain: single institution review analyzing success rate after prior attempts at surgical correction. J Urol2013 189:554–558.
ADDITIONAL READING
• Zipprich J, Murray EL, Winter K, et al. Mumps outbreak on a university campus - California, 2011. MMWR 2012;61:986–989.
• Yapanoglu T, Kocaturk H, Aksoy Y, et al. Long-term efficacy and safety of interferon-alpha-2B in patients with mumps orchitis. Int Urol Nephrol 2010;42:867–871.
See Also (Topic, Algorithm, Media)
• Acute Scrotum
• Mumps Orchitis
• Orchitis, General Considerations Image 
• Orchitis, Granulomatous
• Scrotum and Testicle, Mass
• Testis, Pain (Orchalgia)
• Testis, Tumor and Mass, Adult, General
• Testis
CODES
ICD9
• 604.90 Orchitis and epididymitis, unspecified
• 604.91 Orchitis and epididymitis in diseases classified elsewhere
• 604.99 Other orchitis, epididymitis, and epididymo-orchitis, without mention of abscess
ICD10
• N45.1 Epididymitis
• N45.2 Orchitis
• N45.3 Epididymo-orchitis
CLINICAL/SURGICAL PEARLS
• Most cases of orchitis are viral in nature and self-limited, other cases are bacterial and most commonly associated with epididymitis.
• Physical exam findings include tender, swollen testes with associated erythema of the scrotum with or without fever.
• Testicular ultrasonography is important to rule out torsion and malignancy.
• Medical therapy for orchitis is largely supportive; antibiotic coverage should be targeted to cover STDs in the young and sexually active and UTIs in the elderly.
• The role for surgical management of orchitis is limited.