The most common pathogens responsible for orchitis vary with patient age. In young boys it is usually caused by the mumps virus, leading to parotitis. Men younger than 35 are more commonly infected with sexually acquired organisms, including Chlamydia trachomatis or Neisseria gonorrhoeae. Men over 35 typically demonstrate infection with enteric Gram-negative rods (Escherichia coli), or other - Gram-positive ones (Staphylococcus and Streptococcus). Recent instrumentation with cystoscopy or transrectal ultrasound- (TRUS-) guided prostate biopsy also increases the likelihood of infection with Gram-negative rods.

Another type of Gram-negative bacteria causing a rare endemic enzootic disease called Brucellosis (Mediterranean or Malta fever) may also result in epididymoorchitis. However, although the occurrence of Brucellar epididymoorchitis as the presenting finding is an extremely rare manifestation of Brucellosis, patients can rarely apply to the clinicians with acute scrotum as an initial finding. 

Another risk factor which can cause orchitis is an open inguinal hernia repair. This procedure is widely used for treatment of hernia. Ischemic orchitis typically presents 2–3 days after inguinal hernia surgery and can progress to infarction. Ischemic injury is likely due to thrombosis of the venous plexus, rather than iatrogenic arterial injury or inappropriate closure of the inguinal canal. Although ischemic orchitis, atrophy, and orchiectomy are uncommon complications, all patients should be warned of these potential complications and operative consent should include these risks irrespective of the type of hernia or the surgical approach.

On the other hand, orchitis can be caused by anautoimmune  reaction (autoimmune orchitis) leading to a reduction in fertility. Autoimmune orchitis is rare in humans, compared to anti-sperm antibodies. To study orchitis in the testis, autoimmune orchitis has been induced in the rodent testis. The disease starts with the appearance of testicular antibodies, then movement of macrophages and lymphocytes from the blood stream into the testis, breaking of the physical interactions between the developingsperm and Sertoli cells, entry of neutrophils or eosinophils, and finally death of the developing sperm, leading to infertility.

Associated diseases

Complications

  • unilateral testicular atrophy- occurs in 60% of patiens with orchitis
  • chronic epididymitis
  • testicular infarction
  • scrotal abscess

Risk factors

Orchitis could cause azoospermia, most likely due to testicular tissue necrosis. Necrosis appears to be the dominant cell death pathway in infected testis. Substantial necrotic changes seen in Sertoli cells contribute to impaired spermatogenesis by loss of function in supporting the dependent germ cells.

Azoospermia is associated with very low levels of fertility or even sterility, but many forms are amenable to medical treatment.

Mumps vaccines safely prevent mumps as the major cause of orchitis. When given to a majority they decrease complications at the population level. Practice safe sex to prevent from sexually transmitted infections.

It is possible to apply ice packs to the scrotal area but not directly on skin, because frostbites can be created.  To handle pain and discomfort it is recommended to rest, elevate the scrotum while lying down, wear an athletic supporter and refrain from sex until the infection has cleared. 

Pharmacotherapy

The management of this condition requires intravenous antibiotic therapy and surgical evaluation. However, in most of the cases orchiectomy is not necessary because the conditions are amenable to conservative antibiotic therapy. To relieve pain, it is recommended to use non-steroidal anti-inflammatory drugs such as naproxen or ibuprofen

Surgery

If the testicle is considered nonviable, orchiectomy is performed. 

In patients where orchitis caused azoospermia, microscopic epididymal sperm aspiration (MESA) or testicular sperm extraction (TESEmicroTESE) is the method of choice for recovering spermatozoa for in vitro fertilization (IVF-ICSI). If these surgical retrieval methods are used, then PGS is usually recommended to assess the genetic constitution of the resulting embryos.

In patients, where no own sperm are available, donor sperm should be considerate as an option. Donated embryos may be used in couples, where man has no sperm and quality of woman’s egg are too low, mostly due to her higher age.

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