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reproduction 3- usmle rx bricks

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a complete summary of the reproductive system for step 1 usmle

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  • December 5, 2022
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  • 2022/2023
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Orchitis and Epididymitis
Last Updated: August 13, 2021
access_time13 min
Learning Objectives (2)
After completing this brick, you will be able to:
● Describe the microbiology, clinical features, and treatment of orchitis.
● 1
● Describe the microbiology, clinical features, and treatment of
epididymitis.
● 2

CASE CONNECTION




CO, a 24-year-old man, waits for about a week before coming to see
you about his current symptoms. “First, I had this discharge from my
penis,” he begins. “It wasn’t painful, except when I peed, so I just
ignored it for a while. Now I have this pain in my right testicle, and
any time I touch it or even when I walk, it really hurts. The discharge
is still there too. It’s pretty gross, but it’s the pain that brought me
here. I can’t ignore that anymore.” On physical examination, you
notice a purulent discharge at the tip of CO’s penis. The right scrotum
is mildly erythematous, and there is exquisite pain with palpation over
the posterior epididymis and spermatic cord. The cremasteric reflex is
intact.

,What is your differential diagnosis? How will you explain this
condition to CO? Consider your answers as you read, and we’ll revisit
at the end of the brick.




How Should We Evaluate a Patient
with Testicular Pain?

Most men are familiar with testicular pain. Indeed, it’s a rare man
who has escaped the pain of a misplaced kick or poorly thrown ball
while growing up. Males of any age can experience testicular pain,
and it has many possible causes. But pain in the testicles and scrotum
(the pouch of skin that surrounds and protects the testes) that isn’t the
result of trauma raises special concern. In this brick, we look at two
nonemergent causes of testicular pain. The first, orchitis, is the less
common of the two. Although it can be a complication of sexually
transmitted infection (STI), the most well-known example of orchitis
is the testicular inflammation and pain seen with childhood mumps
infections. The second, epididymitis, is a complication of STI that
normally just causes urethritis.


When clinicians evaluate a patient with acute testicular pain, one of
the first considerations is to determine whether the patient has a
testicular torsion, a time-sensitive emergency that must be identified

,quickly and treated surgically. After addressing this possibility,
attention shifts to other causes that are less emergent.


Orchitis and epididymitis are both infections within the scrotum.

● Orchitis is inflammation in the testicle itself and is typically
caused by an infection.
● Epididymitis, the most common cause of scrotal pain in adults,
is inflammation of the epididymis, which is the coiled tube on
the back of the testicle.
● The testicle and epididymis may both be affected; this is
referred to as epididymo-orchitis.



What Is Orchitis?

Orchitis is a rare acute testicular inflammation. It is usually due to an
infection. Overall, orchitis is most commonly seen in association with
epididymitis (epididymo-orchitis). It is usually seen in adolescent
males.



Clinical Presentation

Orchitis presents with testicular pain and swelling. On examination,
orchitis is characterized by diffuse testicular swelling and exquisite
tenderness. The cremasteric reflex is usually intact, and the Prehn sign
may be positive.

, Etiology

Most orchitis is due to the mumps virus, a paramyxovirus. Mumps
orchitis is bilateral in 30% of cases. Bacterial orchitis is uncommon. It
is usually due to the spread of bacteria (Chlamydia trachomatis and
Neisseria gonorrhoeae) from the epididymis (epididymo-orchitis)
(Table 1). Even less common is autoimmune orchitis, a rare condition
characterized by granuloma formation in the seminiferous tubules
with or without anti-sperm antibodies.


Orchitis: Associations and Causes by Age Group



Children and Teens Young Men (<35 Older Men (≥35 yr)
yr)



Associations Part of overall viral Usually in Usually in
syndrome association with association with
epididymitis due to epididymitis
STIs (pyogenic spread in
these cases);
underlying infection
is commonly
associated with
urologic conditions
(benign prostatic
hypertrophy with
urinary stasis,
urinary tract
infection,
instrumentation)

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