Epididymo-Orchitis

Key points

• Epididymo-orchitis is infection/inflammation involving the epididymis with or without testicular involvement, causing acute scrotal pain and swelling.
• Typical presentation: unilateral scrotal/testicular pain and swelling, often with epididymal tenderness; dysuria, urinary symptoms, fever or urethral discharge may occur.
• Urethral discharge may be present, but urethritis can be asymptomatic. In sexually active men, test for chlamydia and gonorrhoea and assess for other STIs as appropriate.
• Testicular torsion is the critical differential. Sudden severe unilateral pain, particularly in a young patient, an abnormal/high-riding testis or a convincing acute torsion history requires urgent urological assessment/exploration ; ultrasound should not delay surgery when clinical torsion is strongly suspected.
• Current BASHH guidance: the relevant national guideline is the 2020 BASHH guideline , not the 2010 document. Treatment is empiric when objective epididymo-orchitis is diagnosed and is selected according to likely STI versus enteric aetiology; gonococcal disease requires ceftriaxone-based treatment according to current BASHH recommendations.
• MRCP discriminator: sudden severe testicular pain in a young man → torsion until excluded; gradual pain/swelling with epididymal tenderness and STI/urinary features → epididymo-orchitis.
• Current BASHH 2020: sexually acquired disease is commonly treated with ceftriaxone 1 g IM plus doxycycline; enteric causes are treated according to likely organism and resistance/local guidance. Do not use the obsolete 2010 guideline as the current reference.