Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.
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The symptomatology of orchitis is dominated by an acute inflammatory response confined to the scrotum. The most prominent and distressing symptom is testicular pain. This pain is typically rapid in onset, severe, and may radiate to the inguinal canal, groin, and lower abdomen. The radiation pattern is due to the embryological origin of the testis. Because the testes descend from the abdomen during fetal development, they drag their nerve supply and lymphatic drainage with them. Therefore, pain signals travel along these pathways, often creating a sensation of visceral discomfort that can be accompanied by nausea and vomiting.
Physical examination reveals a swollen, indurated, or hardened and exquisitely tender testicle. The scrotal skin overlying the affected testis is often erythematous and edematous due to the local release of histamine and bradykinin, which increase vascular permeability. This scrotal wall edema can be significant, obliterating the standard rugal folds of the skin. In cases of mumps orchitis, the swelling can be massive, with the testicle expanding to several times its standard size. This expansion is contained by the tunica albuginea, leading to a compartment syndrome-like effect in which the increased internal pressure compromises microcirculation, intensifying ischemic pain.
Systemic symptoms are frequent, particularly in viral etiologies. High-grade fever, chills, rigors, and myalgia (muscle aches) reflect systemic viremia or bacteremia. The patient often appears toxic and lethargic. In bacterial epididymo-orchitis, lower urinary tract symptoms may precede or accompany scrotal pain. These include dysuria, frequency, urgency, and, occasionally, urethral discharge, pointing to a retrograde source of infection.
A critical aspect of understanding orchitis symptoms is the need to differentiate it from testicular torsion. Torsion is a surgical emergency where the spermatic cord twists, cutting off the blood supply to the testicle. The symptoms of acute scrotal pain, swelling, and nausea overlap significantly. However, certain clinical signs help distinguish them.
In orchitis, the pain is often more gradual in onset over hours to days compared to the sudden, explosive onset of torsion. The cremasteric reflex, which is the elevation of the testicle when the inner thigh is stroked, is usually preserved in orchitis but absent in torsion. Additionally, the Prehn sign may be positive in orchitis. This describes the relief of pain when the scrotum is manually elevated, which reduces the weight drag on the inflamed cord. In torsion, elevation typically does not relieve pain and may worsen it. Despite these signs, the overlap is substantial, and any acute scrotal pain requires immediate medical evaluation to rule out torsion and save the testicle.
For the demographic of sexually active men under the age of 35, sexual behavior is the primary driver of risk. Unprotected sexual intercourse facilitates the transmission of Neisseria gonorrhoeae and Chlamydia trachomatis, the leading causative agents of bacterial epididymo orchitis in this group. Having multiple sexual partners or a history of prior STIs significantly elevates the risk.
Interestingly, sexual activity itself can sometimes be a mechanical trigger. Engaging in strenuous physical activity with a full bladder or sexual activity that involves withholding ejaculation can theoretically increase the risk of refluxing urine into the vas deferens, causing a chemical orchitis or epididymitis even in the absence of bacteria or sterile inflammation. This underscores the mechanical aspect of risk, where pressure dynamics within the urogenital tract facilitate the pathological migration of fluids.
The risk profile for developing orchitis is influenced by anatomical and physiological factors that predispose the urinary tract to infection and reflux. Benign Prostatic Hyperplasia plays a significant role in older men. An enlarged prostate obstructs the flow of urine, resulting in high residual urine volumes in the bladder. This creates a stagnant pool for bacteria to multiply. During voiding, the high pressure required to push urine past the prostate can force infected urine backwards into the ejaculatory ducts and vas deferens, initiating the path to the testis.
Urethral strictures, narrowing of the urethra from scar tissue, also cause obstruction and reflux, increasing the risk of ascending infection. Anatomical anomalies, such as congenital abnormalities of the urinary tract, including ectopic ureters or posterior urethral valves in children, can predispose to recurrent infections that may involve the testicles. These structural issues create a hydrodynamic environment that favors retrograde pathogen movement against the natural flow of urine.
Modern medicine introduces its own set of risks. Long-term indwelling urinary catheters are a significant risk factor for nosocomial or hospital-acquired orchitis. The catheter acts as a foreign body and a highway for bacteria to bypass the urethra’s natural defenses. Instrumentation of the urinary tract, such as cystoscopy or transurethral surgery, can also introduce bacteria or cause trauma that leads to infection.
Systemic immune status plays a role. Patients who are immunocompromised due to HIV, diabetes, or chemotherapy are at higher risk for both typical and atypical forms of orchitis, such as fungal or mycobacterial infections. Furthermore, the lack of vaccination remains a potent risk factor for viral mumps orchitis. In populations with low MMR vaccine coverage, mumps outbreaks can result in a significant incidence of orchitis among adolescent and adult males.
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The Prehn sign is a physical exam finding used to help distinguish between epididymo-orchitis and testicular torsion. It is considered positive if lifting the testicle relieves the pain. This relief occurs because lifting the testicle off the inflamed area reduces tension. In testicular torsion, lifting usually does not help and may increase pain. However, this sign is not fully reliable.
Yes, a moderate to high fever is a common symptom of orchitis, mainly when caused by mumps or severe bacterial infections. The fever reflects the systemic immune response to the pathogens invading the testicular tissue. Chills, sweating, and a general feeling of malaise or flu-like illness often accompany it.
An enlarged prostate or BPH blocks the normal flow of urine out of the bladder. This forces the bladder to squeeze harder, which can push urine backward or cause it to reflux into the reproductive tubes connecting to the testicles. Additionally, the bladder often fails to empty, leaving a stagnant pool of urine where bacteria can grow and spread to the testicles.
Yes, having a urinary catheter in place for a long time is a significant risk factor. The catheter keeps the urethra open and provides a surface for bacteria to climb up into the bladder. Once in the bladder, these bacteria can easily migrate down the vas deferens to infect the testicles, especially in patients with weakened immune systems.
No, testicular pain can be caused by many conditions. The most dangerous is testicular torsion or twisting, which cuts off blood flow. Other causes include trauma, kidney stones causing referred pain, hernias, varicocele, or cysts. Because torsion is an emergency that can lead to loss of the testicle within hours, sudden pain should always be evaluated immediately.
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