Orchitis

What is orchitis?

Orchitis refers to inflammation (-itis) of the testicle (orkhis). Orchitis is a painful, potentially dangerous infection of the male genitals. It can occur due to viral or non-viral causes.

The first symptoms to arise are usually fever, headache, malaise (or a general ill-feeling), and swollen salivary glands (parotitis), followed by swollen, painful testicles that may occur unilaterally (one side) or bilaterally. You may also experience painful urination, blood in your urine or semen, and pain in the surrounding area of the testicles.

The best defense against orchitis is vaccination with the MMR vaccine in childhood. If the cause is viral, treatment options are mainly supportive. Treatment for non-viral orchitis may involve surgery to restore blood flow to the testicle or antibiotics if the cause is bacterial in nature.

Antibiotics are needed to treat bacterial orchitis. If the cause is viral, ibuprofen, acetaminophen, and ice packs may be used to treat symptoms.

Orchitis symptoms

Main symptoms

The tell-tale symptoms that distinguish orchitis from other infections include the following.

• Testicular pain/swelling: For mumps orchitis, testicular symptoms typically begin one to two weeks after the first signs of constitutional symptoms (fever/headache/malaise) and swollen salivary glands in the jaw (known as parotitis).
• Unilateral or bilateral: Orchitis is usually unilateral (affecting one side) but can also be bilateral (affecting both sides).

Other symptoms

Other systemic symptoms of orchitis that do not affect the testicles include the following.

• Fever: This is the most common systemic symptom, sometimes seen along with headache and malaise, often beginning earlier in the course of infection up to two weeks before orchitis sets in.
• Painful urination: Also known as dysuria, painful urination can be seen in bacterial orchitis, particularly when caused by sexually transmitted bacteria or urinary tract infections.
• Blood in the urine or semen: It is also possible to see blood in the urine (known as hematuria) or the semen (hematospermia), particularly in non-viral orchitis.
• Thigh or scrotum pain, swelling, and redness: Orchitis from any cause can also be accompanied by pain, swelling, and redness of tissues around the testicles such as the scrotum or thigh.

Long-term complications

Possible long-term complications of orchitis include the following.

• Testicular atrophy and resultant infertility: Among those who develop orchitis, up to half will show some loss of functional testicular tissue. It makes sense that this could disrupt the reproductive function of the testicles, and trouble fathering children is a frequent concern after recovery from orchitis. Impaired fertility is a known complication of orchitis, but thankfully true sterility is quite rare. It is more common after bilateral oddities when both testes are affected, but even then most men are ultimately able to have children.
• Testicular cancer: Some studies have also found higher rates of testicular cancer, however, there’s not enough evidence to say if this was truly caused by orchitis.

Orchitis causes

Orchitis is classically caused by viral infection, particularly infection by the mumps virus. Up to one-third of post-pubescent men infected with mumps will develop orchitis, particularly adolescents. Rates of mumps orchitis plummeted after introduction of the MMR vaccine against measles, mumps and rubella.

Thanks to the success of the MMR vaccine, the annual incidence of mumps infection in the United States fell from around 150,000 cases in 1968 to less than 3,500 by 1983, or a decrease of 99 percent. Deaths from mumps fell more than tenfold. Sadly, in recent decades, mumps has appeared more frequently, particularly due to an outbreak in 2006. This year had the most mumps cases in three decades. This is largely due to a downturn in vaccination due to a suggested link between the MMR vaccine and the presence of autism. This claim has been repeatedly and thoroughly disproven.

Bacterial causes

Less often, orchitis can be caused by bacteria instead of a virus. This usually takes the form of epididymo-orchitis, starting as an infection of nearby tissue, known as the epididymis, then spreading to the testicle itself. In young men, epididymo-orchitis is most often caused by sexually transmitted bacteria such as chlamydia or gonorrhea. Other types of bacterial infection (e.g. brucellosis) can also cause orchitis, particularly in children or older men.

Non-infectious causes

Since orchitis simply means inflammation of the testicle, it can include non-infectious causes. The most common is ischemic orchitis where blood flow to the testicle is impaired, often due to an entrapped hernia.

Treatment options and prevention for orchitis

Prevention

As with most viral infections, there is no known cure for mumps orchitis. The most effective strategy available is preventing the disease before it starts. That means protecting children with appropriate vaccination, administered according to the schedules recommended by the Centers for Disease Control and Prevention (CDC). Almost all recent mumps orchitis cases have been in unvaccinated men. No vaccine is 100% effective, largely because people with impaired immune systems can’t mount an appropriate response. That said, the MMR vaccine is safe and highly effective. Once infection sets in, there is no effective treatment to cure the disease.

Treatment for viral orchitis

Other treatment strategies for viral orchitis are largely supportive. Several treatment strategies have been attempted using anti-mumps antibodies (or immunoglobulins), but nothing has shown convincing efficacy so far. Supportive treatment is directed at reducing pain and inflammation.

• Pain relief: This is mainly achieved with ice and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin). As a rule, children should not be given aspirin and people with certain medical conditions (e.g. kidney disease) should not take NSAIDs.
• Sling for localized support: A scrotal sling may also provide relief by elevating and supporting the inflamed tissue.
• Other pain relief methods: Attempts have been made at more aggressive control of pain with local anesthetic injections and inflammation control with corticosteroids or surgery, but these are generally believed to do more long-term harm than good.

Treatment for non-viral orchitis

As one would expect, treatment of non-viral orchitis involves addressing the underlying cause.

• Surgery: In the case of ischemic orchitis, blood flow must be restored to the testicles, usually via surgery.
• Antibiotics: For bacterial orchitis, the mainstay of treatment is antibiotics. While the specific antibiotic regimen may vary depending on the specific bacteria seen from your urine test and overall clinical picture, it’s likely to expect a short course of antibiotics.
• Pain relief: Supportive care with anti-inflammatories is similar to that described above for viral orchitis.

When to seek further consultation for orchitis

It’s unlikely that orchitis will be the first sign of infection, but it may be the one that tips you over into seeking medical care.

If you are experiencing testicular pain

Patients or parents concerned for unexplained testicular pain should see their doctor promptly. While orchitis is actually a relatively rare cause of testicular pain, very similar symptoms can be seen in the far more common cases of epididymitis or testicular torsion. Torsion occurs when twisting of the testicle cuts off blood flow, which can progress rapidly to ischemic orchitis and tissue loss. It can occur after trauma or spontaneously without any clear trigger. Unlike bacterial or viral orchitis, torsion is a medical emergency which requires immediate surgical intervention. Since lab tests and ultrasound imaging are often needed to determine the cause of testicular pain, prompt medical evaluation is warranted.

If you are recovering from orchitis

Regardless of the specific cause, symptoms of orchitis should not last more than a few weeks. If symptoms fail to improve despite following the proper treatment regimen, it’s worth following up with your doctor. After symptom resolution, further testing or monitoring is rarely needed. Despite valid concerns about fertility problems, true infertility is very rare. Routine testing of fertility after orchitis is is not necessary, nor would it be particularly helpful in most cases. That said, anyone having trouble achieving pregnancy should let their doctor know about previous infections or genital tissue damage, including any history of orchitis.