Epididymo-orchitis — Rapid | Doctor’s Passport

Synopsis

Distinguish epididymo-orchitis from testicular torsion, identify sexual and enteric causes, prescribe cause-directed therapy and complete partner and follow-up management.

Epididymo-orchitis usually causes unilateral epididymal pain and swelling developing over hours to days; torsion is the time-critical mimic.
Age alone does not determine cause: use sexual history, urethral symptoms, urinary pathology, anal exposure, instrumentation and culture.
Send first-catch urine NAAT for gonorrhoea and chlamydia and midstream urine culture when enteric infection is possible.
Do not allow Doppler ultrasound to delay emergency exploration when clinical suspicion of torsion is high.
For likely gonorrhoea or chlamydia, give ceftriaxone 1 g intramuscularly once plus doxycycline 100 mg twice daily for 10 to 14 days.
For likely mixed sexual and enteric exposure, ceftriaxone 1 g once plus levofloxacin 500 mg once daily for 10 days is an option.
When gonorrhoea is excluded and enteric organisms are likely, ofloxacin 200 mg twice daily for 14 days or levofloxacin 500 mg daily for 10 days may be used under current restrictions.
Advise rest, scrotal support, analgesia and abstinence until treatment and partner management are complete; review if not improving within three days.

Key red flags

Sudden severe pain or a high-riding testis requires immediate torsion assessment.

Sepsis, rapidly spreading erythema, crepitus or disproportionate pain suggests Fournier gangrene.

A fluctuant mass, persistent fever or worsening swelling suggests abscess or infarction requiring urology.

Bilateral symptoms, mumps features or immune compromise widens the infectious differential.

A persistent testicular mass after treatment requires urgent assessment for malignancy.

Torsion pattern

Abrupt severe pain, nausea, high-riding or horizontal testis and absent cremasteric reflex increases torsion probability and requires emergency urology.

Severe soft-tissue infection

Perineal necrosis, bullae, crepitus, rapidly spreading erythema or disproportionate pain suggests Fournier gangrene rather than uncomplicated disease.

Investigation priorities

Focused genital and abdominal examinationFirst step

Localise epididymal tenderness and assess torsion, hernia, abscess and perineal necrosis.

Management branches

TORSIONProtect the ischaemic testis

Onset, testicular lie, nausea or examination creates meaningful suspicion of testicular torsion.

Contact urology immediately, document onset, give analgesia, keep the patient fasted and prepare for emergency exploration.
Do not wait for urine results, improvement after analgesia or routine outpatient ultrasound when suspicion is high.
Manual detorsion may be attempted only by an experienced clinician when surgery is not delayed and does not replace exploration and fixation.
Continue reassessing both testes and communicate any diagnostic uncertainty directly to the operating urologist.

Key medicines

Ceftriaxone plus doxycyclineGive ceftriaxone 1 g intramuscularly once plus doxycycline 100 mg orally twice daily for 10 to 14 days.Check severe beta-lactam allergy, obtain gonococcal culture when feasible, avoid doxycycline in pregnancy and review photosensitivity, oesophagitis and interacting cations.

Ceftriaxone plus levofloxacinGive ceftriaxone 1 g intramuscularly once plus levofloxacin 500 mg orally once daily for 10 days.Use levofloxacin only under MHRA restrictions; review renal, tendon, neurological, psychiatric, vascular, cardiac and glycaemic risk and interactions.

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