Orchitis

What is orchitis?

The testicles make sperm and testosterone. Each sits in the scrotum with the epididymis, a coiled tube that stores sperm, along its back. Infection usually reaches the testicle in one of two ways:

• From the urinary tract or sexual partner, traveling down the vas deferens to the epididymis and then the testicle. This is epididymo-orchitis, and most bacterial orchitis is this type. See epididymitis for inflammation limited to the epididymis.
• Through the bloodstream, as with the mumps virus. This causes isolated orchitis.

Causes

Bacterial orchitis

Rarer causes include tuberculosis and brucellosis.

Viral orchitis

• Mumps: orchitis develops in a significant share of males who catch mumps after puberty, typically 4 to 8 days after the swollen salivary glands appear. Up to about a third of these cases affect both testicles. Mumps orchitis is uncommon in vaccinated populations but occurs in outbreaks, often among students.
• Other viruses, including Coxsackie, Epstein-Barr and varicella, occasionally cause it.

Noninfectious causes

Injury, autoimmune inflammation and certain medicines rarely cause orchitis.

Symptoms of orchitis

• Pain in one or both testicles, ranging from aching to severe
• Swelling, warmth and redness of the scrotum
• A tender, heavy testicle
• Fever, chills and feeling unwell
• Nausea
• With epididymo-orchitis: burning on urination, urgency, or discharge from the penis
• With mumps: swollen cheeks or jaw before the testicle pain

Pain usually builds over hours to a day or two, which helps distinguish it from torsion.

Orchitis vs testicular torsion

Testicular torsion is a twist of the cord carrying blood to the testicle. It is a surgical emergency, usually in boys aged 12 to 18, and must be ruled out first.

When in doubt, doctors operate rather than wait, because a twisted testicle may not survive beyond about 6 hours.

Diagnosis

• Exam of the scrotum, groin and abdomen, and a check for urethral discharge
• Urine test for infection, and a nucleic acid amplification test (NAAT) on urine for chlamydia and gonorrhea
• Urine culture, especially for older men
• Doppler ultrasound of the scrotum to confirm inflammation, check blood flow and look for an abscess
• Mumps testing (saliva swab or blood antibodies) if mumps is suspected
• Testing for HIV and syphilis if an STI is found

Treatment

Bacterial orchitis

Antibiotics are started straight away, before test results, based on the most likely cause:

• Likely STI: an injection of ceftriaxone plus oral doxycycline, per current CDC guidance
• Likely urinary bacteria: an oral fluoroquinolone such as levofloxacin, or another antibiotic guided by culture
• Both possible (for example insertive anal sex): a combination

Treatment usually lasts 10 days or more. Sexual partners from the previous 60 days need testing and treatment for STI-related cases, and you should avoid sex until both of you finish treatment and symptoms are gone. Severe cases with high fever, vomiting or an abscess need hospital care and IV antibiotics.

Viral orchitis

Antibiotics do not help mumps orchitis. It is treated with:

• Rest and scrotal elevation
• Cold packs for 15 to 20 minutes several times a day
• Pain relief with acetaminophen (paracetamol) or ibuprofen at the label dose

Pain usually improves within a week; swelling and tenderness may take several weeks to settle.

Home care for all types

• Wear supportive underwear or an athletic supporter
• Lie down with a rolled towel under the scrotum
• Drink plenty of fluids and rest
• See your doctor again if not improving within 3 days of antibiotics

Complications

• Abscess in the testicle or scrotum, which may need drainage
• Testicular atrophy: shrinking of the affected testicle, common after mumps orchitis
• Reduced fertility: usually temporary; permanent infertility is rare, mainly after severe orchitis in both testicles. See male infertility
• Chronic testicular pain
• Low testosterone, rarely
• A slightly higher association with testicular cancer has been suggested after mumps orchitis, but evidence is limited

Prevention

• MMR vaccine: two doses protect most people against mumps; a third dose may be offered during outbreaks
• Condoms and regular STI testing if you have new or multiple partners
• Prompt treatment of urinary infections and prostate problems

Frequently asked questions

What is the main cause of orchitis?

In sexually active men under 35, the main cause is chlamydia or gonorrhea spreading to the epididymis and testicle. In older men, it is usually urinary tract bacteria. Mumps is the most common viral cause, especially in unvaccinated teenagers and young adults.

How long does orchitis last?

With antibiotics, bacterial orchitis usually improves within a few days, although tenderness and swelling can take 2 to 4 weeks or longer to settle. Mumps orchitis pain usually eases within about a week, with swelling resolving over several weeks.

Can orchitis cause infertility?

It can, but permanent infertility is uncommon. Sperm counts may drop for a few months. The risk is highest after mumps orchitis affecting both testicles, which can cause atrophy. One healthy testicle usually maintains normal fertility and testosterone.

What is the difference between orchitis and epididymitis?

Epididymitis is inflammation of the epididymis, the coiled tube behind the testicle. Orchitis is inflammation of the testicle itself. Bacterial infections often involve both, called epididymo-orchitis. Mumps typically causes orchitis without epididymitis.

Is orchitis contagious?

Orchitis itself is not passed on, but the infections behind it can be. Chlamydia and gonorrhea spread through sex, so partners need testing and treatment. Mumps spreads through saliva and respiratory droplets, mainly in the days around the onset of swollen glands.