Emergency Medicine

ACUTE ABDOMEN

Surgical Emergencies 271

Acute epididymo-orchitis

DIAGNOSIS

1 This occurs in sexually active men with a preceding history of urethritis,
or following urinary tract infection or instrumentation including
catheterization.

2 Pain begins gradually and is usually localized to the epididymis or testis,
associated with a low-grade fever.

3 Send a FBC to look for a neutrophilia and request a urine microscopy to look
for leucocytes.

MANAGEMENT

1 Never diagnose epididymo-orchitis in a patient <25 years old without
considering testicular torsion first (see below).

2 Give the patient a scrotal support if torsion has been excluded, analgesics
such as paracetamol 500 mg and codeine phosphate 8 mg two tablets q.d.s.,
and an antibiotic.

3 The choice of antibiotic depends on the suspected aetiology:
(i) Sexually acquired epididymo-orchitis
Give ceftriaxone 500 mg i.v. daily for 3 days, plus azithromycin
1 g orally once, plus either another 1 g orally 1 week later or
doxycycline 100 mg orally b.d. for 14 days
(a) arrange follow-up in a genitourinary medicine clinic, and
partner treatment.
(ii) Bacterial cystitis with epididymo-orchitis
Give cephalexin 500 mg b.d., or amoxicillin 875 mg with
clavulanic acid 125 mg one tablet b.d., or trimethoprim 300 mg
once daily, all for 14 days and refer to the urology clinic.

Acute testicular torsion

DIAGNOSIS

1 Suspect this diagnosis in any male under 25 years with sudden pain in a
testicle, which may radiate to the lower abdomen. There may be associated
nausea and vomiting.

2 The testicle lies horizontally and high in the scrotum, and is very tender.
There may be a small hydrocoele.

3 Urinalysis is typically negative and the blood white cell count normal.

MANAGEMENT

1 Always refer every suspected case urgently to the urology team, as the testicle
becomes non-viable after 6 h of torsion.