Sexually Transmissible Infections in Clinical Practice

13. A Man with Scrotal Pain

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Michael, a 21-year-old man, presents to an Emergency Department with a 5 h history of pain and swelling of the left scrotum. The pain came on gradually and is increasing in severity. He has not noticed urethral discharge or dysuria, and there has been no frequency, hesitancy, or urgency of micturition, nocturia, hematuria, or abdominal or loin pain. There is no history of trauma. His general health is good and he is not receiving any medication.

Michael, a 21-year-old man, presents to an Emergency Department with a 5 h history of pain and swelling of the left scrotum. The pain came on gradually and is increasing in severity. He has not noticed urethral discharge or dysuria, and there has been no frequency, hesitancy, or urgency of micturition, nocturia, hematuria, or abdominal or loin pain. There is no history of trauma. His general health is good and he is not receiving any medication.

13.1 What Are the Causes of Acute Scrotal Pain?

Table 13.1 shows some causes of acute scrotal pain.

Table 13.1.

Some causes of acute scrotal pain.

Acute epididymo-orchitis

Testicular torsion

Trauma

Torsion of the appendix testis or of the epididymis

Hemorrhage or infarction of a testicular tumor

Testicular infarction associated with, for example, autoimmune diseases or leukemia

The history alone can only really exclude trauma as a cause of his pain.

The left scrotal skin is reddened (Fig. 13.1 ). There is tenderness and swelling of the left epididymis but because of the presence of a hydrocoele, the testis cannot be palpated. There is a mucoid urethral discharge.

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Figure 13.1.

Left scrotal redness and swelling.

13.2 What Is the Most Likely Diagnosis?

The most likely diagnosis is acute epididymitis, probably associated with chlamydial infection (see Case 5). However, testicular torsion must be excluded. In the typical patient with torsion, there is a sudden onset of pain in the affected side of the scrotum, sometimes with nausea and vomiting. The testis often lies more horizontal than usual and is high in the scrotum. The lower pole of the affected testis is exquisitely tender. When these features are present, surgical exploration is mandatory. The viability of the testis that has undergone torsion depends on the degree of torsion and the duration of symptoms, and surgical intervention should be undertaken as soon as possible after onset of symptoms. Clinical signs are not always reliable, but imaging studies may give valuable assistance.

An ultrasound examination of the scrotum is performed. The epididymis is swollen and hypoechoic but the testis appears normal.

This finding confirms the clinical diagnosis. It should be noted that torsion of the testis is not easy to diagnose by real-time scrotal ultrasonography. Color Doppler ultrasound, however, is useful in differentiating acute torsion from epididymo-orchitis, particularly when sophisticated equipment and “power” Doppler are used. In torsion, blood flow is either absent or reduced, whereas in epididymo-orchitis it is increased. Ultrasonography cannot diagnose all cases of torsion – false-negative results do occur – and if there is doubt about the diagnosis surgical exploration is indicated.

13.3 What Are the Causes of Acute Epididymo-Orchitis?

Table 13.2 lists the causes of epididymo-orchitis.

Table 13.2.

Causes of epididymo-orchitis.

Chlamydia trachomatis

Neisseria gonorrhoeae

Urinary tract pathogens, e.g., Escherichia coli

Mumps

Amiodarone (used in the treatment of arrhythmias)a

Mycobacterium tuberculosis b

Mycobacterium leprae b

Brucella spp.b

Systemic fungal infections, e.g., histoplasmosisb

Filariasisb

aRare.

bRare in industrialized countries.

In young men (under the age of 35 years), epididymitis is usually associated with a sexually transmitted infection, particularly Chlamydia trachomatis. In industrialized countries where access to medical care is good, gonococcal epididymo-orchitis is rare. Acute epididymitis in older men (over 35 years of age) usually occurs as a result of a complicated urinary tract infection, usually due to coliform organisms. This does not imply that sexually transmitted infections do not cause epididymo-orchitis in older men – a sexual history should be elicited. The prevalence of coliform infection in epididymo-orchitis in young men who have sex with men who have had unprotected insertive anal intercourse is higher than in men who have sex with women. As anatomical abnormalities of the urinary tract are common in men with Gram-negative bacterial infections, especially in those aged 50 years and over, urological investigations are indicated in this group of patients.

In mumps, epididymo-orchitis complicates about 20% of cases in adults, with one in six showing bilateral involvement. Scrotal swelling is usually noted within a week of parotid enlargement, but sometimes only when the clinical signs of mumps have disappeared.

Michael is referred immediately to a Sexual Health clinic.

He has been sexually active for about 3 years and has had four partners in that time. For the past 2 months he has been in a regular sexual relationship with an 18-year-old woman, his only sexual partner for more than 1 year. As she uses a progesterone-only implant for contraception, they do not use condoms for vaginal sex. She is symptomless.

A Gram-stained smear of urethral material shows more than 10 polymorphonuclear leucocytes per ×1,000 microscopical field; Gram-negative diplococci are not identified. Specimens for the detection of chlamydial and gonococcal infections are taken as described in Case 1and a mid-stream specimen of urine is sent to the laboratory for culture for urinary tract pathogens. He agrees to serological testing for syphilis and HIV. Treatment is initiated without waiting for the laboratory test results.

Table 13.3 shows the currently recommended regimens for the treatment of epididymo-orchitis.

Table 13.3.

Drug treatment of acute epidiymo-orchitis.

For presumed gonococcal infection:

 

Ceftriaxone 250 mg as single intramuscular injection

 

PLUS

 

Doxycycline 100 mg twice daily by mouth for 10–14 days

 

For presumed chlamydial infection:

 

Doxycycline 100 mg twice daily by mouth for 10–14 days

 

For presumed infection with Gram-negative bacteria:

 

Ofloxacin 200 mg twice daily by mouth for 14 days

 

OR

 

Ciprofloxacin 500 mg twice daily by mouth for 10 days

 

Michael is treated with doxycycline for 14 days. He is also advised to rest and to abstain from sexual intercourse until he and his partner has completed treatment. For analgesia, ibuprofen, a non-steroidal anti-inflammatory drug, is prescribed. Partner notification is also completed during this clinic visit. His girlfriend attends the clinic the next day for screening and empirical treatment with a single oral dose of 1 g of azithromycin.

Michael is reviewed 3 days after initiation of therapy. There has been considerable improvement in his symptoms, and the epididymis is less tender.

The results of the tests taken at the initial attendance are available: a nucleic acid amplification test for C. trachomatis was positive, but Neisseria gonorrhoeae was not detected. Serological tests for syphilis and HIV were negative.

13.4 If There had been no Significant Improvement at This Time, What Conditions Would You Then Consider?

Failure to have improved at this time would have prompted a reassessment of the original diagnosis (Table 13.4).

Table 13.4.

Conditions that may be associated with failure to respond to antimicrobial drugs in a man with suspected epididymo-orchitis.

Testicular, or rarely, epididymal neoplasm

 

Testicular ischemia or infarction

 

Testicular infarction or abscess formation, particularly with gonococcal infection or pyocele of the scrotum, as a complication of pyogenic bacterial orchitis

 

Tuberculous epididymo-orchitis

 

Mumps orchitis

 

Fungal epididymo-orchitis

 

When Michael attends the clinic 1 month later he is symptomless. The right epididymis remains swollen and firm but is not tender.

Thickening of the epididymis can persist for several months, and further intervention at this stage is not indicated.