AKT · Sexual health/Syndromeslow yield

Epididymo-orchitis

35y or insertive anal sex: coliforms (E. coli)

Overview

Inflammation of the epididymis ± testis. Aetiology is age-stratified — STI in younger men, enteric organisms in older men — which determines empirical therapy. The key emergency to exclude is testicular torsion.

Recognise

Unilateral gradual-onset scrotal pain and swelling
Tenderness localised to the epididymis; possible urethral discharge or UTI symptoms
Positive Prehn sign (pain relief on elevation) — unreliable

Red flags

SUDDEN severe pain in a young man → exclude testicular torsion (surgical emergency, <6h) FIRST

Differentials & how to tell them apart

Testicular torsionSUDDEN onset, younger, high-riding testis, absent cremasteric reflex, NO relief on elevation — emergency surgery

Strangulated herniagroin mass, bowel symptoms

Testicular tumourpainless hard mass, not acutely inflamed

Investigations

Assess torsion risk urgently (Doppler USS if any doubt). NAAT (STI) + MSU/urine culture (enteric). The cause is decided by age/history.

Management

STI-likely: ceftriaxone 1 g IM + doxycycline 100 mg BD ×10–14d

1EXCLUDE torsion first. If STI likely (<35y or risk factors): ceftriaxone 1 g IM single + doxycycline 100 mg BD ×10–14d.Gate: If enteric organisms most likely (older, low STI risk, UTI/instrumentation) → a quinolone (e.g. ofloxacin) instead
2Supportive: analgesia, scrotal support, rest.

Ceftriaxone + doxycycline — if STI likely (<35y / risk): ceftriaxone 1 g IM + doxycycline 100 mg BD ×10–14d

Ofloxacin / quinolone — if enteric organisms likely (>35y, low STI risk)

Key points

Never attribute acute scrotal pain to infection until torsion is excluded — torsion needs surgery within hours.

Monitor & prognosis

Response at review; exclude abscess/torsion if not improving.

Good if treated; torsion missed → testicular loss.

Source: BASHH epididymo-orchitis; NICE CKS Scrotal pain