Sexually transmitted infections

• Chlamydia trachomatis
• Neisseria gonorrhoea
• Mycoplasma Genitalium (limited data)
• Gram-negative enteric pathogens (in men engaging in insertive anal sex)

Non-sexually transmitted infections

• Gram negative enteric organisms
  • Ecoli
  • Pseudomonas
  • Proteus
  • Klebseilla
  • Salmonella
• Other bacteria possible but less likely (Staph aureus)

Other infections

• Tuberculous
  • Subacute, bilateral in 34% , scrotal fistulas can occur
• Brucellosis
  • 2-20% will develop epidydmorchitis
• Mumps
  • 20-25% of adult males with mumps will develop orchitis (1 week after initial symptoms)
  • 424 mumps cases confirmed January 2019-June 2019 in Scotland
• Candida (In immune-compromised or following instrumentation to urinary tract)

Other rare causes

• Vasculitis
  • Behcets
  • HSP
  • Polyarteritis
• Amiodarone
  • <1% of users, dose and duration related
• BCG therapy for bladder cancer

• Usually unilateral scrotal pain and swelling
• Acute onset (develops over days) (<6 weeks = acute)
• Localised tenderness to palpation of epidydmis
• Possibly associated with urethral discharge, dysuria and penile irritation
• Possibly associated with symptoms of UTI (dysuria, frequency, urgency)
• +/- reactive hydroecele
• +/- Systemically unwell, fever

The most important differential diagnosis is testicular torsion. A sudden onset of painful

swollen testicle in a young man is testicular torsion until proven otherwise. This is a surgical

emergency and requires urgent referral to urologist.

Indications increasing likelihood of torsion; if sudden onset; severe pain; colicky nature of the pain; no associated symptoms; (e.g. discharge) Negative Prehn’s sign *; and lack of cremasteric reflex.

*Prehns sign = Elevation of scrotum relieves pain

But any concerns refer to urology as time crucial 

• If concern re torsion – refer immediately to BGH via Urology on-call bleep through BGH switchboard.

If not:

• Microscopy of urethral smear
• Culture if Gonorrhoea
• NAATs for CT/GC
• MSU
• Bloods – FBC and CRP – (will be useful for follow up) and HIV/STS as part of SHS
• Other Investigations in keeping with suspected diagnosis i.e. Brucella IgG
• No clear evidence to test for Mycoplasma genitalium at this point, not recommended here routinely. BASSH recommend to consider (evidence 2D). If specific concerns discuss with GUM Senior.

• Information, Explanation of causes
• Can give copy of BASHH PIL eo_pil_mobile-pdf_04.pdf (bashhguidelines.org)
• Analgesia
• Rest
• Scrotal support
• Sexual abstinence during treatment + treatment of partners if sexually active

Antibiotic Treatment

1^st line

• Ceftriaxone 1gram IM
• And Doxycycline 100mg bd for 14 days

 2^nd line

• Ofloxacin 200mg bd for 14 days
  • New guidance advises
    • Avoid if previous tendon problems secondary to quinolone
    • Avoid co-administration with corticosteroid due to increased risk of tendon rupture
    • Caution if >60, renal impairment or previous transplant due to increased risk of tendon problems
    • Co-administration with NSAID increases risk of seizures

3^rd line

• Trimethoprim 200mg bd for 14 days

 If M gen positive and suspected cause

• Moxifloxacin 400mg od for 14 days 

At 3 days

• Advise all patients to call if symptoms not improving
• Can check MSU and NAATs and switch antibiotic if indicated
• Bloods should have been seen day after appointment but if can recheck/ repeat if necessary

 At 2 weeks

• Assess response to treatment
• Check sexual abstinence
• Check Partner notification
• Test of cure if Gonorrhoea
• Review diagnosis – consider rarer causes
• If symptoms not settled refer to urology/ arrange US
  • 5% of testicular tumours can present with acute pain
• If uropathogen identified as cause refer routinely to urology as 20% will have anorectal malformations.

Short term

• Hydrocoele
• Testicular Ischemia/ Infarction
  • Rare, usually secondary to missed torsion
• Abscess
  • Severe cases can lead to abscess formation, may need I&D

Long term

• Epidydymal obstruction – If inadequately treated leads to scarring and obstruction of epidydymis can lead to sub-fertility
• Chronic Pain

Current partners should have full screen and further PN as per diagnosis. (not required if non STI)