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Epididymo-orchitis
Torsion first — then STI vs enteric cover.
| If you find… | …then |
|---|---|
| Sudden-onset severe testicular pain, especially under 25 | Testicular torsion — urology now; don’t delay for scans |
| High-riding testis, absent cremasteric reflex | Torsion — urology now |
| Abscess, systemically unwell | Urology / admit |
| Fournier’s gangrene features (perineal pain, crepitus, systemic illness) | Surgical emergency |
- Onset (sudden vs gradual), severity
- Urinary symptoms, urethral discharge
- Sexual history (partners, condom use)
- Recent instrumentation/catheter
- Mumps exposure/vaccination
- Obs
- Testicular lie, swelling, tenderness (epididymis posterior)
- Cremasteric reflex
- Urethral discharge; inguinal nodes
Torsion is clinical
You can’t reliably exclude torsion with an exam or a scan. Sudden severe pain in a young man means urology now, because time to surgery saves the testis.
STI or enteric?
Under 35 and sexually active → usually chlamydia/gonorrhoea. Older, after instrumentation, or with urinary tract problems → usually enteric organisms. Cover appropriately.
Could this be torsion?
- Sudden onset of severe pain
- Age under 25
- High-riding / horizontal testis
- Absent cremasteric reflex
- Nausea and vomiting with the pain
Any present: Torsion not excluded → urology immediately (don’t wait for a scan). None present: Gradual epididymal pain → treat as epididymo-orchitis.
| Investigation | Only if… |
|---|---|
| First-void urine NAAT (chlamydia/gonorrhoea) | All sexually active |
| MSU dip and culture | Enteric organisms |
| Urgent ultrasound | Only if it doesn’t delay surgery when torsion is possible |
Management & advice
- Scrotal support, analgesia, rest
- Likely STI: refer to sexual health for partner notification; abstain until treated (and partners treated)
- Follow-up to ensure resolution
Refer / follow-up
- Possible torsion → urology immediately
- Likely STI → sexual health (partner notification)
| Drug | Dose | Duration / notes |
|---|---|---|
| Likely STI: ceftriaxone BNF ↗ | 1 g IM single dose | Plus doxycycline (below) — per BASHH |
| Plus doxycycline BNF ↗ | 100 mg twice a day | 10–14 days |
| Likely enteric (e.g. older, instrumentation): ofloxacin BNF ↗ | 200 mg twice a day | 14 days (fluoroquinolone safety warnings) |
| Paracetamol BNF ↗ | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
| Ibuprofen BNF ↗ | 400 mg three times a day with food | 3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy |
This is an infection of the tube behind the testicle, not a twisted testicle. Take the antibiotics for the full course, wear supportive underwear and take painkillers. If it might be sexually transmitted, the sexual health clinic will help test and treat partners, and avoid sex until treatment is finished. Come back immediately if the pain suddenly gets much worse.
Come back / call 111 — or 999 if severe — if:
- Pain suddenly becomes much worse
- Fever, feeling very unwell, swelling or redness spreading
- Not improving within 3 days
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
- Calling torsion epididymitis
- Not testing for STIs
- No partner notification
Revision practice. Work through a real or imagined case to rehearse the reasoning. It builds a model note to learn from. It doesn’t replace your judgement, your seniors or local guidance.
✎Blank clinic note template
Epididymo-orchitis — clinic note
Doses are typical doses drawn from the guidance above. Always confirm in the current BNF/BNFc and your local antimicrobial policy.