A 16 year old boy presents with acute onset pain in the left testis. The following staements about his management are true except
EPIDIDYMO-ORCHITIS Inflammation confined to the epididymis is epididymitis; infection spreading to the testis is epididymo-orchitis. Pathophysiology Infection reaches the epididymis the vas from a primary infection of the urethra, prostate or seminal vesicles. A general rule is that epididymitis arises in sexually active young men from a sexually transmitted genital infection, while in older men it more usually arises from a urinary infection or may be secondary to an indwelling urethral catheter. In young sexually active men, the most common cause of epididymitis is now Chlamydia trachomatis, but gonococcal epididymitis is still occasionally seen. In older men with bladder outflow obstruction, epididymitis may result from a urinary infection - it is proposed that a high pressure in the prostatic urethra might cause reflux of infected urine up the vasa. Blood-borne infections of the epididymis are less common but may be suspected when there is epididymal infection without evidence of urinary infection; it is presumably the only possible mechanism in men who have previously undergone a vasectomy. Acute epididymo-orchitis can follow any form of urethral instrumentation and it is paicularly common when an indwelling catheter is associated with infection of the prostate. Infection usually stas in the tail of the epididymis and spreads to the rest of the epididymis and occasionally to the testis. Complications include abscess formation, testicular infarction, testicular atrophy, chronic induration and inflammation and infeility. Clinical features While there may be initial symptoms of a urinary or a genital infection, such symptoms are not always seen. The development of an ache in the groin and a fever can herald the onset of epididymitis. The epididymis and testis swell and become painful. The scrotal wall, at first red, oedematous and shiny, may become adherent to the epididymis Investigation should include a urethral swab, a urine specimen for culture, nucleic acid amplification testing (NAAT) of either a urine specimen or a urethral swab and scrotal ultra- sound. Urinalysis will usually show leukocytes and may show a formal urinary tract infection. NAAT is a sensitive way of identifying both gonoccal and chlamydial urethritis. Ultrasound is useful in the initial assessment of epididymitis and will identify abscess formation. In adolescents, the differential diagnosis is testicular torsion and if there is any clinical doubt as to the diagnosis then testicular exploration should always be performed. Treatment Either doxycycline (100-200 mg daily) or a quinolone should be the initial treatment in young men. There should be contract tracing of the paner and treatment if necessary. Antibiotic treatment should continue for at least 2 weeks. In older men, quinolones are the usual initial treatment, but if there is evidence of systemic sepsis, then intravenous antibiotics directed at urinary pathogens may be valuable. If an organism is isolated from the urine, this simplifies the choice of antibiotic. All patients should drink plenty of fluid. Local measures including scrotal suppo and analgesia are helpful. Antibiotic treatment should continue for at least 2 weeks or until the inflammation has subsided. If suppuration occurs, drainage is necessary. Ref: Bailey and love 27th edition Pgno : 1505
The patient should be prescribed antibiotics and asked to come after a week
Colour flow Doppler will be very useful in diagnosis
Scrotal exploration should be done without delay if doppler is not available
If left testis is not ble on exploration, patient should undergo left Orchidectomy and right orchidopexy.
Urology