Orchitis is an inflammatory process of testicular tissues caused by bacterial or viral pathogens, testicular injuries. Symptoms include enlargement of the scrotum, pain, swelling, hyperemia and fever. The appendage of the testicle is often involved in the pathological process, which is expressed by pain in the inguinal region. The diagnosis is confirmed by ultrasound of the scrotum organs. PCR diagnostics are carried out to exclude the venereal nature of the disease. Treatment involves the appointment of an antibiotic, taking into account sensitivity to the drug, NSAIDs, physiotherapy. With purulent melting of tissues or necrosis, an operation is performed.
N45 Orchitis and epididymitis
Men face testicular inflammation at any age. Orchitis is often diagnosed in men at the peak of sexual activity (18-35 years old), who have the greatest risk of infection with STDs, and in patients over 50 years old with prostate hyperplasia and concomitant obstruction. In 80-90% of cases, orchitis occurs in combination with epididymitis, in 9% the lesion is bilateral. Gonococci and chlamydia are most often isolated from venereal pathogens, intestinal and Pseudomonas aeruginosa, proteus, staphylococci and streptococci are isolated from non-specific microflora. The viral nature of orchitis prevails in boys. In a number of observations, Koch’s wand can initiate the development of genitourinary tuberculosis involving testicles.
Testicular inflammation is a multifactorial disease. It develops when infected with pathogens of a viral nature, specific or non-specific bacterial microflora. In some patients, it is impossible to determine the cause – then they talk about the idiopathic form, which is most difficult to treat. The connection of orchitis (orchoepididymitis) with taking certain medications, some systemic diseases is described.
In children, bacterial orchitis is more often caused by congenital anomalies (ectopic ureter or vas deferens, congenital valves, diverticulum, etc.) or functional disorders associated with the presence of residual urine (dysinergia of the bladder sphincter). These changes are accompanied by recurrent urinary tract infection, which, under appropriate conditions, spreads to testicular tissues. The main etiofactors leading to orchitis are:
- Viral infections. Viral infection more often provokes orchitis in children under 15 years of age, in about 20% of cases, testicular inflammation complicates epidemic mumps, in adults this figure is 10-15%. There is some data on the development of orchitis after immunization for mumps, measles and rubella. Less common causes include chickenpox and Coxsackie viruses, cytomegalovirus, adenoviruses.
- Urological diseases. Orchitis can be caused by a bacterial infection that often spreads from neighboring inflamed structures of the urogenital tract: prostate, vesicles, appendages. Bacterial microflora can enter the testicular tissue with blood flow from any focus of inflammation in the body. In elderly patients, against the background of an enlarged prostate or urethral stricture, adequate urine outflow is disrupted, which is complicated by the formation of urethrovesical reflux with the development of epididymitis, and then orchitis. Testicular tumor leads to reactive tissue inflammation.
- Injuries and iatrogenic injuries. Infection of testicular tissue is facilitated by surgical interventions (TOUR, open surgery, lithotripsy), urological manipulations (bougie, catheterization), diagnostic procedures (urethrocystoscopy, pyeloscopy), in which the integrity of the mucous membranes is violated. Orchitis often develops after being bitten by animals or insects, due to injury. Initially, aseptic inflammation with the addition of a secondary bacterial infection turns into purulent orchitis.
- Venereal infections. Sexually transmitted diseases can cause orchitis in sexually active men. The path of infection is contact ascending, initially specific inflammation develops in t he urethra. Without the necessary therapy, gonococci, chlamydia, mycoplasma, trichomonas affect the prostate, appendages, testicles and other organs.
The main predisposing factor includes immunosuppression of any genesis (HIV infection, diabetes mellitus, severe infectious diseases, etc.). Men receiving chemoradiotherapy or taking hormones, immunosuppressants have a higher risk of developing orchitis. In these patients, the initiators of testicular inflammation may be candida albicans, toxoplasma gondii, cryptococci, etc.
Orchitis is mainly considered as a complication of acute epididymitis caused by the spread of the pathological process in the testicular tissue by perivasal and interstitial pathways. Inflammation is supported by a violation of blood and lymph outflow, compression of tissue due to accumulation of exudate, increased pressure in the ducts and seminal tubules. In the absence of treatment, serous inflammation turns into a purulent form, microabsesses are formed, which can self-resolve with the formation of a fibrous scar or, when merged, form a testicular abscess. Focal or diffuse sclerosis of testicular tissues leads to a violation of spermatogenesis, as functioning structures are lost.
The path of infection with mumps and other viral infections is hematogenic, the virus spreads throughout the body, and glandular organs (including testicles) are target organs. In patients infected with mumps, during the first few days the virus attacks the testicular glands, causing inflammation of the parenchyma, destruction of the seminal tubules and perivascular lymphocytic infiltration.
Clinical symptoms are variable and depend on the severity of the pathological process and the nature of the pathogen. Common manifestations may include weakness, fever with chills, headache, muscle aches. The disease can occur acutely, which is typical for men with gonorrhea, or develop within a few days – it depends on the characteristics of the immune status.
The affected testicle is enlarged in size, sharply painful, the skin above it is hyperemic. Swelling due to inflammation can be so pronounced that it is not possible to probe any structures in the scrotum on the side of the lesion. In the supine position, painful sensations manifest themselves less.
Discharge from the urethra can be pronounced: the secret is usually abundant, whitish or yellowish-green, with an unpleasant odor, which causes suspicion of the venereal nature of the disease. The inguinal lymph nodes may be enlarged. Urination disorders are present in 35% of patients, dysuria symptoms are represented by cuts, frequent urges, discomfort in the perineum.
Chronic orchitis has less pronounced symptoms. The temperature rises only with exacerbation, pulling pains, aching, increase after physical exertion, during and after sexual contact, during defecation. Localization of painful sensations – testicle, inguinal region, perineum. The appearance of blood in semen may indicate the involvement of vesicles in the process.
With epidemic mumps, orchitis is often preceded by general weakness, an increase in the salivary glands (swelling in the parotid region), fever, chills, difficulty swallowing. In 20% of patients, testicular inflammation joins on 4-7 days. In 70% of cases, the lesion is unilateral, contralateral involvement of the second sex gland occurs on 1-9 days.
Complications with timely access to a urologist and compliance with all recommendations are rare. After bilateral orchitis, spermatogenesis is disrupted in 87% of patients, azoospermia occurs in 3-5% of cases. Within 12 months, the improvement of ejaculate indicators occurs in 90% of men. In the absence of adequate antibacterial therapy, reactive dropsy, pyocele, testicular abscess may develop (in 3-8%).
Chronization of the process can also be considered as a complication of acute inflammation, while sclerotic and dystrophic changes are the cause of obstructive and/or secretory infertility. 60% of men who have had orchitis are diagnosed with a slight decrease in the size of the testicle – atrophy, which is not always accompanied by changes in the spermogram. Sepsis is a potential consequence of severe infection.
A preliminary diagnosis can be established on the basis of anamnesis and physical examination data, a number of instrumental and laboratory tests are necessary to determine the genesis of the inflammatory process. It is mandatory for a urologist to conduct a finger rectal examination of the prostate gland, since orchitis and prostatitis often occur in combination. The patient can be referred for consultation to a phthisiourologist, oncologist, surgeon. The algorithm of examination in orchitis:
- Laboratory diagnostics. To exclude / confirm STIs, PCR tests are prescribed for Neisser’s gonococci and chlamydia trachomatis. The study is necessary if a large number of leukocytes are visualized with a conventional smear microscopy from the urethra. Cultural studies aimed at identifying bacterial pathogens and sensitivity to drugs are carried out. Orchitis on the background of viral mumps is confirmed by the determination of antibodies by the ELISA method. Changes in the general blood test are nonspecific, with pronounced inflammation there is a shift of the leukocyte formula to the left, increased ESR.
- Instrumental diagnostics. Ultrasound of the scrotum with a doppler allows you to assess the condition of the affected testicle, exclude concomitant pathologies, for example, tumor, testicular torsion, abscess. In doubtful cases (if the tumor genesis of reactive orchitis is suspected), magnetic resonance imaging of the scrotum and pelvic organs is performed. Diaphanoscopy demonstrates heterogeneity of testicular tissue, but the informative value of this method remains low.
Differential diagnosis is performed with testicular torsion. It is characterized by a sudden onset of pain, there is no prodromal period with an increase in temperature. The diagnosis is confirmed by an ultrasound scan with a Doppler, in which the rotation of the genital gland relative to the normal anatomical location, compression of the vessels and nerves of the spermatic cord is clearly visible. The testicle itself is more often of normal size. Similar clinical symptoms are present in the infringement of inguinal-scrotal hernia. Consultation with a surgeon and ultrasound of the scrotum is enough to establish a diagnosis.
Hospitalization in a hospital is indicated if purulent complications cannot be excluded or they are expected in a patient against the background of immunosuppression. The regime is bed rest, for the relief of symptoms, it is recommended to wear a suspension. Spicy dishes and alcohol are excluded from the diet. An enhanced drinking regime is prescribed to relieve intoxication and increase diuresis, which accelerates the elimination of pathogens from the body.
Treatment begins empirically, without waiting for the results of bakposev and PCR diagnostics. With viral orchitis, the appointment of antibiotics is considered inappropriate. Inflammation, supported by any venereal infection, implies simultaneous treatment of a sexual partner. Complex therapy of bacterial testicular inflammation includes:
- Taking medications. Antibiotics are prescribed with the widest possible spectrum of action. The duration of the course is determined individually, with concomitant prostatitis, medications are taken up to 4 weeks. After receiving the results of bakposev, if necessary, the treatment regimen is adjusted. Nonsteroidal anti-inflammatory drugs are used to reduce pain, reduce fever. NSAIDs and antibacterial drugs enhance the effect of each other.
- Local impact. In the first hours, cold is applied to reduce edema (a cold heating pad wrapped in a cloth), then resorbing compresses are applied to the side of the lesion. Physiotherapy in the acute period is not carried out, but as the inflammation subsides, after 3-5 days, UHF therapy, electrophoresis, laser-magnetic exposure are possible. With chronic inflammation, physiotherapy helps to prevent exacerbation.
- Surgical treatment. With the development of purulent-destructive complications, orchiectomy is resorted to. Some practitioners consider justified early surgical intervention, which consists in applying incisions to the protein shell, which reduce compression and allow the purulent contents to flow away. Despite the fact that the operation is organ-preserving, undesirable consequences are possible in the form of the formation of fibrosis sites with a violation of spermatogenesis.
Prognosis and prevention
With adequate therapy, most cases of orchitis proceed without complications, the prognosis for life is favorable. When inhibiting spermatogenesis, timely consultation with an andrologist is important. If infertility therapy is unsuccessful, it is possible to turn to assisted reproductive technologies. Sometimes recurrent orchitis is a consequence of incomplete diagnosis, which requires a comprehensive examination and adequate treatment.
Preventive measures include adherence to monogamous relationships, the use of protective equipment when practicing traumatic sports. Timely referral to a urologist at the first symptoms of problems on the part of the genitourinary organs, periodic examination of patients suffering from chronic urological pathology, and preventive treatment minimize the risk of orchitis. Men who did not suffer from viral mumps in childhood and did not receive vaccination should avoid contact with people with mumps.