BMJ 2011: 342: 883 – 932 (23rd April)

More useful stuff on testicles.  In this case, one article on testicular cancer and one on epididymo-orchitis.  The article on testicular cancer was mostly specialist stuff, but did contain the useful point that testicular cancer doesn’t necessarily present as an obvious lump – 20% of cases present with scrotal pain, 11% with backache, 7% with gynaecomastia, and an unspecified percentage with ‘dragging sensation in the scrotum’.  The article was less than helpful on what pointers us non-specialists should be looking for to help us decide who to refer out of people with those rather non-specific symptoms, but did say that ‘orchitis not resolving within two to three weeks’ should be referred for assessment at a 2ww clinic.  I have added my own mental note to consider testicular examination as part of the examination of men with back pain.

More directed at my level was the article about epididymo-orchitis, which, for starters, mentioned some possible signs to be found on examination – erythema (and, later, oedema) of the scrotum, tenderness/thickening of the epididymis, and reduction of pain by elevating the testis with the patient standing (I did remember that one from medical school but could never remember whether it was torsion or epididymo-orchitis it was meant to apply to.  It’s epididymo-orchitis.  Glad to have clarified that.)  Of course, if in any doubt you’re going to be referring to exclude a torsion anyway, but for that small proportion that you feel OK to diagnose and treat in the community there was, I was pleased to see, advice on appropriate antibiotics.

Firstly, decide whether it’s likely to be an STI.  If:

  • the patient is over 35
  • sexual history is low risk
  • there is no urethral discharge
  • urinalysis is positive for nitrites (with or without leucocytes – dipsticks positive to leucocytes only are apparently more characteristic of STIs)

then you can generally treat as not likely to be an STI.  Recent catheterisation or a past history of UTI also, of course, point towards a non-STI cause.

If it is likely to be an STI, the treatment is Ciprofloxacin 500 mg stat plus Doxycycline 100 mg bd for 14 days.  Ceftriaxone 250 mg IM is an alternative to the Cipro, but who’s got that lying around to give?  (GUM clinics, that’s who.)  Advise GUM clinic for screening and avoid sex until review, and discuss partner notification.  If you happen to know that it’s likely to be chlamydia or some other non-gonococcal organism, you can skip the Cipro/Cef, and you can also use Ofloxacin 200 mg bd for 14 days as an alternative to the Doxycycline, if you wish.

If it isn’t an STI, treatment is Ciprofloxacin 500 mg bd for 14 days or Ofloxacin 200 mg bd for 14 days.

Substantial improvement in pain/erythema should be expected within 3 to 5 days, so tell patients to get back in touch if no improvement in 3 days, at which point you send them in to exclude a scrotal abscess.

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, Testicular problems, Urology. Bookmark the permalink.

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