🔑 Key Learning
- Unilateral scrotal pain with swelling and fever suggests epididymo-orchitis.
-
Most common causes:
-
<35 years: STI (Chlamydia trachomatis, Neisseria gonorrhoeae)
- Ceftriaxone + Doxycycline
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>35 years: UTI pathogens (E. coli, Proteus, Klebsiella)
- Ofloxacin or levofloxacin
-
<35 years: STI (Chlamydia trachomatis, Neisseria gonorrhoeae)
🦠 Aetiology
| Age Group | Common Cause |
|---|---|
| <35 | STI (Chlamydia, Gonorrhoea) |
| >35 | UTI/enteric pathogens (E. coli, Proteus, Klebsiella, Pseudomonas) |
Risk Factors:
- Bladder outflow obstruction, BPH, prostate Ca.
- Recent urological instrumentation or catheter
👀 Clinical Features
Symptoms
- Acute onset unilateral scrotal pain, swelling and erythema
- Fever, rigors
- Dysuria, frequency, urethral discharge
Examination
- Unilateral, firm and tender epididymal swelling
- Scrotal oedema and erythema
- Prehn’s sign positive – pain relieved by scrotal elevation
- Must exclude torsion: sudden pain, N&V, absent cremasteric reflex
🧪 Investigations
- First-pass urine NAAT for CT/NG
- Urine dipstick ± MSU for culture
- Consider STI screen and sexual health referral in <35 or at-risk
💊 Management
1. Likely STI-related (age <35 or STI risk factors)
- Ceftriaxone 1g IM stat
- Plus Doxycycline 100mg BD for 14 days
2. Likely UTI/enteric cause (age >35 or recent catheter)
-
Ofloxacin 200mg BD for 14 days
or - Levofloxacin 500mg OD for 10 days
3. Mixed risk (e.g. MSM, anal sex)
- Ceftriaxone 1g IM stat
- Plus Ofloxacin 200mg BD for 10 days
📝 Exam Clues & Clinchers
- Age <35 with STI risk → CT/NG
- Ceftriaxone + Doxycyline
-
Recent catheter / BPH history → Enteric organisms
- Ofloxacin
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MSM or insertive anal sex → treat for both STI + UTI organisms
- Ceftriaxone + Ofloxacin