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Epididymo-orchitis in primary care:
is management adequate?
VAIBHAV MODGIL, PAUL STURCH, TARIG ABDELRAHMAN, ANGIE RILEY,
SUMIT BHADURI, CHRIS HEATH, JOSHUA PHILLIPS AND PAUL RAJJAYABUN
Acute epididymo-orchitis
is a common and increasing
problem for GPs, which,
if untreated, carries risks
of significant sequelae,
including infertility. Recent
literature suggests widespread
suboptimal management
of epididymo-orchitis in
secondary care, in spite of
published guidelines. In this
article, the authors evaluated
adherence to these guidelines
in primary care.
cute epididymo-orchitis is a clinical
diagnosis consisting of pain and
swelling of the epididymis and/or testes
(Figure 1). The most common route of
infection is local extension from the
urethra (sexually transmitted pathogens) or
bladder (urinary pathogens).1 It is the fifth
most common urological diagnosis in the
18–50 age range, responsible for more lost
man hours in the US military than any
other urological condition.2
A
AETIOLOGY OF EPIDIDYMO-ORCHITIS
In the UK, acute epididymo-orchitis is a
common and increasing problem, with
patients frequently presenting to their GP.
A recent study using the NHS General
Practice Research Database identified more
than 12 000 patients presenting with
epididymo-orchitis over a five-year period,
57 per cent of whom were treated entirely
in primary care.3
TRENDS IN UROLOGY & MEN’S HEALTH
MARCH/APRIL 2012
Epididymo-orchitis is predominantly an
acute inflammatory process; however,
if left untreated, chronic inflammation
may develop, with sequelae of abscess
formation, testicular infarction, testicular
atrophy and infertility.4
The aetiology can be categorised largely by
patient age, with a peak incidence in the
third decade and 70 per cent of cases
occurring between 20 and 39 years.5 In
most patients aged 35 years or less,
infection is sexually transmitted, with
Chlamydia trachomatis isolated in
approximately 85 per cent of cases,
followed by Neisseria gonorrhoea.5
In spite of substantial evidence of the growing
public health problem caused by untreated
C. trachomatis, a recent study highlighted
that secondary epididymo-orchitis is poorly
managed by urologists in hospital.6 It should
also be recognised that cases of epididymoorchitis related to sexually transmitted
infections offer an opportunity to perform
sexual health screening and contact tracing.
On this background, in 2001 the National
Strategy for Sexual Health and HIV
encouraged a greater role for primary care
physicians in the treatment of sexually
transmitted infections.
Figure 1. Acute epididymo-orchitis, showing
inflammation of the testes. ”Dr P. Marazzi/
Science Photo Library
Vaibhav Modgil, BM, MRCS, ST3 Urology, West Midlands Deanery; Paul Sturch, MB ChB,
BSc, MRCS, Core Surgical Trainee, Wessex Deanery; Tarig Abdelrahman, BM, MRCS, ST3
General Surgery, Wales Deanery; Angie Riley, MB ChB, GPVTS, North West Deanery; Sumit
Bhaduri, MB ChB, FRCP, Consultant in Genitourinary Medicine, Worcestershire Acute NHS
Hospitals Trust; Chris Heath, MB ChB, DCH, DRCOG, MRCGP, GP, St John’s Surgery,
Bromsgrove; Joshua Phillips, MD, FRCS(Urol), Consultant Urological Surgeon, Royal
Bournemouth Hospital; Paul Rajjayabun, MD, FRCS(Urol), Consultant Urological Surgeon,
Worcestershire Acute Hospitals NHS Trust.
www.trendsinurology.com
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GUIDELINES FOR MANAGEMENT OF
EPIDIDYMO-ORCHITIS
Published guidelines from the British
Association for Sexual Health and HIV
(BASHH)1 and the European Association
of Urology7 offer clear and specific
recommendations for investigation and
management of urinary/genital tract
infections.
Standard
No. of patients (%)
Nucleic acid studies on first-catch urine for
chlamydia testing
All patients to have midstream urine sent for
enteric organisms
Doxycycline or ofloxacin
Duration of treatment: 14 days
2 (3)
8 (14)
13 (23)
0
Table 1. Investigation of epididymo-orchitis in 57 primary care patients
Following the exclusion of testicular
torsion, in suspected cases of epididymoorchitis, nucleic acid amplification testing
should be used to diagnose C. trachomatis
or N. gonorrhoea infection, in combination
with microscopy and culture of a midstream
urine sample.
Opportunistic screening of patients with
sexually transmitted epididymo-orchitis
should be undertaken and all patients with
a urinary tract pathogen should be referred
for urological assessment to exclude
structural abnormalities or urinary tract
obstruction.
Empirical treatment should include
doxycycline if sexually transmitted
organisms are the most likely aetiology,
or ofloxacin if enteric organisms are
suspected. Partner notification and
treatment is recommended for all patients
with epididymo-orchitis secondary to
sexually transmitted organisms.
STUDY TO EVALUATE ADHERENCE
TO GUIDELINES
The aim of this study was to evaluate
adherence to established guidelines in
the management of epididymo-orchitis
identified in primary care.
A comprehensive retrospective review of
electronic records held in three primary
care centres across the country was
performed (Bromsgrove, West Midlands;
Portsmouth, Hampshire; Oldham,
Lancashire). All patients presenting with
testicular or scrotal pain over a 12-month
period were initially included. From this
group, 57 patients (median age 26 years,
www.trendsinurology.com
Standard
No. of patients (%)
Referral to hospital for follow-up
Referral to urology for follow-up
Referral to genitourinary medicine
18 (31)
14 (25)
5 (8)
Table 2. Follow-up care in 57 primary care patients
range 15–34) with a final diagnosis of
epididymo-orchitis were identified
(Bromsgrove, n=23, Portsmouth, n=14,
Oldham, n=20).
Consultation details were reviewed, along
with microbiological request/results and
prescribed antibiotic regimens. Additional
clinical information was extracted from
case notes, including supplementary
investigations, treatment and follow-up
recommendations. These data were then
scrutinised for adherence to published
guidelines.1,7
Results of the study
From the 57 patients identified, two
(3 per cent) were formally investigated for
chlamydia with a urethral swab or firstcatch urine, one of which tested positive
(Table 1). Midstream urine samples were
sent in eight cases (14 per cent); one tested
positive for enteric organisms. Chlamydia
studies were inappropriately requested on
a midstream urine specimen in one case.
Microbiological confirmation of an
infective organism was achieved in only
two cases (3 per cent).
The most commonly prescribed antibiotic
was ciprofloxacin (28 per cent). Twentythree per cent of patients were prescribed
a recommended antibiotic (doxycycline
or ofloxacin); however, none of the
patients received treatment for 14 days
(Table 1).
Only 31 per cent of cases were referred
onwards for secondary care assessment
(25 per cent had urology follow-up
arranged). In spite of clear recommendations
that all patients treated for epididymoorchitis be referred to genitourinary medicine
(GUM) clinics at the earliest opportunity, only
8 per cent of cases were referred, and only
half of these attended (Table 2).
Diagnosis of sexually transmitted
infections
Because of the long-term sexual health
implications of chlamydia infection
and the potential impact on the NHS,
a national chlamydia screening
programme was introduced in 2003.8
Rising public awareness of chlamydia
has resulted in an increased uptake
of screening.9 The cost-effectiveness
of these screening programmes is yet
to be proven.
Young men presenting with epididymoorchitis represent an important group of
patients in whom prompt treatment could
reduce the adverse health for both the
index case and associated sexual contacts.
Unfortunately, our data suggest that
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MARCH/APRIL 2012
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management of epididymo-orchitis in
the community falls markedly short of
recommended guidelines. General
practitioners appear to be failing to
diagnose sexually transmitted infections,
including chlamydia, when faced with
secondary complications such as
epididymo-orchitis.
Suboptimal treatment
We identified suboptimal treatment
regimens, including incorrect choice of
antibiotic and duration of the course of
treatment. This could lead to risk of
residual and recurring infection with
further sexual transmission. Limiting the
choice of antibiotic to ofloxacin alone,
which covers both sexually transmitted and
enteric organisms, may help to simplify the
management of epididymo-orchitis in
primary and secondary care before referral
to GUM services.10
REFERENCES
1.
2.
3.
4.
5.
Inadequate referral
Few patients in our cohort were
appropriately referred on to GUM/urology
clinics for review, with even smaller
numbers attending their appointments.
This leads to inadequate follow-up and
also prevents a second chance to enable
contact tracing.
6.
7.
CONCLUSION
Poor management of epididymo-orchitis
is not isolated to healthcare in the
community. A study carried out in various
UK teaching hospitals confirmed that
urologists remain poor at managing
epididymo-orchitis in sexually active young
men in secondary care.6
Our evidence suggests that collaboration
between primary care, GUM teams and
urologists is required to develop
programmes of education and training
to improve the management of this
important patient group and enhance
compliance with existing guidelines and
recommendations.
Declaration of interests: none declared.
www.trendsinurology.com
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British Association for Sexual Health
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TRENDS IN UROLOGY & MEN’S HEALTH
MARCH/APRIL 2012