Retrospective review of the management of epididymo-orchitis in a London-based level 3 sexual health clinic: an audit of clinical practice

Introduction

Epididymo-orchitis is a distressing clinical syndrome characterised by epididymal and/or testicular discomfort, pain and swelling. ¹ In the longer term, this inflammatory condition may be associated with significant sequelae. ² Prompt investigation and treatment are therefore crucial in order to alleviate symptoms and reduce the burden of morbidity. In cases secondary to sexually transmitted pathogens, which serve as the commonest cause of epididymo-orchitis in the below 35-year age group, early treatment will also reduce the risk of onward transmission. ³ Chlamydia trachomatis and Neisseria gonorrhoeae represent the most frequently identified pathogens within this age group. ⁴ Uropathogens are the most common aetiological agents in those over 35 years of age. ⁴

The British Association for Sexual Health and HIV (BASHH) epididymo-orchitis guidelines provide recommendations for the management of this condition. ¹ The aim of this audit was to evaluate the extent to which these guidelines are being followed in the John Hunter Clinic for Sexual Health, Chelsea and Westminster Hospital.

Methods

A retrospective analysis of our electronic patient records (EPR) was used to identify all patients attending the clinic between 1 January 2015 and 30 June 2015, who were diagnosed with epididymo-orchitis. We used the Sexual Health and HIV Activity Property Type (SHHAPT) clinical coding to identify these individuals. Case notes were reviewed and patients were excluded if they had already commenced antibiotics prescribed by another department, clinic or healthcare facility.

Case notes were assessed using the following auditable outcomes as specified in the BASHH guidelines:

The following recommended microbiological investigations are performed: Gram-stained urethral smear, urethral swab or first pass urine for C. trachomatis and N. gonorrhoeae (nucleic acid amplification test or culture) identification and a mid-stream urine (MSU) for microscopy and culture.

Results

A total of 57 patients were identified, ranging from 16 to 67 years of age (median age of 32 years). Thirty-seven patients (64.9%) were heterosexual and 20 (35.1%) were men who have sex with men (MSM). The demographic data, investigations performed and treatment are described in Table 1. Two patients were excluded from the analyses as they had already been started on antibiotics by a hospital emergency department. In both cases, the patient had been prescribed oral ciprofloxacin.

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Table 1.

Demographics, investigations and antibiotics given for epididymo-orchitis.

	Age ≤ 35 years	Age > 35 years	Total
Number of patients (%)	36/57 (63.2)	21/57 (36.8)	57
Urethral smear performed (%)	34/36 (94.4)	17/21 (81.0)	51/57 (89.5)
First pass urine collected for CT and NG NAAT (%)	36/36 (100)	20/21 (95.2)	56/57 (98.2)
Urine collected for microscopy and culture (%)	24/37 (64.9)	18/21 (85.7)	42/57 (73.7)
Proportion of those tested who had ≥ 5 PMNLs per high power field × 1000 on urethral smear microscopy (%)	18/34 (52.9)	4/17 (23.5)	22/51 (43.1)
Proportion of those tested for CT that were positive by NAAT (%)	5/36 (13.9)	0/20 (0)	5/56 (8.9)
Proportion of those tested for NG that were positive by NAAT (%)	0/36 (0)	1/20 (5)	1/56 (1.8)
Proportion of those tested that had a positive mid-stream urine result (%)	1/24 (4.2)	1/18 (5.6)	2/42 (4.8)
Proportion of all patients that had a sexually transmitted pathogen identified (%)	5/36 (13.9)	1/21 (4.8)	6/57 (10.5)
Proportion of all patients that had 1 or more positive microbiological laboratory results (%)	19/36 (52.8)	4/21 (19.0)	23/57 (40.4)
BASHH-recommended antimicrobial regimen given (%)	36/36 (100)	21/21 (100)	57/57 (100)
Ofloxacin 200 mg orally BD for 14 days (%)	33/36 (91.7)	15/21 (71.4)	48/57 (84.2)
Doxycycline 100 mg orally BD for 14 days (%)	3/36 (8.3)	6/21 (28.6)	9/57 (15.8)
Ceftriaxone 500 mg IM single dose given as an additional antibiotic to cover for possible NG (%)	4/36 (11.1)	2/21 (9.5)	6/57 (10.5)

Forty-one patients (71.9%) had all four microbiological investigations performed. All 57 patients in this study received one of the antibiotic regimens recommended in the BASHH national guidelines. All patients were given the option to have a follow-up appointment, telephone follow-up or to return if their symptoms failed to resolve.

Five (8.8%) patients reported non-resolution or only partial resolution of their symptoms. One of these patients’ symptoms settled with a further seven days of ofloxacin (21 days in total). This 35-year-old patient had urethral smear findings indicative of urethritis but a pathogen was not identified. A second 32-year-old patient had an urgent ultrasound and a further follow-up appointment arranged but failed to attend either. The third, a 40-year-old patient, had clinical and ultrasound findings consistent with an epididymal cyst and negative microbiology. The fourth patient, a 32-year-old man, had clinical and ultrasound findings consistent with a varicocoele and also had negative microbiology. The fifth, a 34-year-old patient, had repeatedly negative examination and microbiological findings; therefore, subsequent follow-up with his General Practitioner was planned.

Discussion

This audit demonstrated that all patients who attend our clinic were treated with antimicrobials in concordance with the national guidelines and the vast majority showed a good clinical response. Eighty-four percent of patients received ofloxacin which is effective against C. trachomatis and other non-gonococcal pathogens, as well as enteric organisms. ¹ The shortfall in our clinical practice was urine sampling for microscopy/culture (performed in 73.7% of patients). This was particularly the case in the 35 years and below age group. However, this group did have higher proportion of patients undergoing urethral smear sampling for evidence of urethritis compared to those aged over 35 years, which may have been influenced by the reported aetiological differences between the two age groups. Eleven of the 15 patients who did not have an MSU for microscopy/culture did, however, have urine dipstick analysis performed. There may have been additional patients who did have a urine dipstick performed but the result of which was not documented. Although a urine dipstick was performed in most cases (84.2%), guidelines do stipulate that this only serves as a useful adjunct. As a result of this audit, our department intends to obtain an MSU for microscopy and culture in all cases of epididymo-orchitis. Given that only 23 of our 57 patients (40.4%) had one or more positive microbiological findings, it is important to perform all the recommended investigations in order to try to maximise the diagnostic yield.

The urine sample of one patient (aged below 35 years) was found to contain group B streptococcus. This pathogen is not amongst the most common causes of urinary tract infections in adults but is associated with underlying urinary tract anomalies. ⁵ Importantly, this patient reported a family history of urinary tract anomalies and was subsequently referred for further investigation. In another patient, aged over 35 years and who had a positive MSU culture, the growth of Escherichia coli was found, and this patient responded to treatment with ofloxacin.

Our results were consistent with previous observations of sexually transmitted pathogens being the predominant cause in people aged 35 years and below. ⁴ A recent study, in which patients with epididymitis over a six-year period were extensively investigated utilising both routine methods and advanced molecular diagnostics, identified sexually transmitted pathogens in 42% of antibiotic-naive patients below 35 years of age (22.5% C. trachomatis; 7.9% Mycoplasma species; 2.3% N. gonorrhoeae). ⁶ In our analysis, only 13.9% of all patients aged 35 years and below tested positive for a sexually transmitted pathogen; however, 50.0% had a urethral smear with five or more polymorphonuclear cells indicative of a urethritis. There was no documented testing of Mycoplasma genitalium in the patients included in this audit but testing for this pathogen has more recently become readily available in our clinic. It may therefore be important in the future to consider testing for other pathogens such as Mycoplasma species, particularly in patients who test negative for C. trachomatis and N. gonorrhoeae and fail to respond to the initial antimicrobial therapy. It is also important to note that when patients with suspected epididymo-orchitis are seen in other clinical settings, such as a urology clinic, the patient characteristics along with aetiological agents may differ with possibly a lower proportion of sexually transmitted infections in the urological setting.

A final, additional observation was that the two patients we excluded from the analysis, who were already started on antibiotics by a hospital emergency department, were given ciprofloxacin. Both patients were heterosexual men below 35 years of age. Although they may still be at risk of enteric pathogens, particularly if they engage in anal sex, C. trachomatis remains the commonest cause of epididymo-orchitis in this age group. C. trachomatis is not reliably treated by ciprofloxacin and is not recommended in our antibiotic guidelines. ⁷ It is therefore important to educate and highlight our local and national guidance to the hospital emergency department staff and other doctors such as general practitioners who manage this condition.