A Descriptive Analysis of Men Diagnosed With Epididymitis, Orchitis, or Both in the Emergency Department

Abstract

Introduction
Epididymitis and orchitis are illnesses characterized by pain and inflammation of the epididymis and testicle. They represent the most common causes of acute scrotal pain in the outpatient setting. Epididymitis and orchitis have both infectious and noninfectious causes, with most cases being secondary to the invasive pathogens chlamydia, gonorrhea, and Escherichia coli (E.coli). The study's objective was to examine the epidemiology and clinical characteristics of men diagnosed with epididymitis or orchitis in a United States emergency department.
Methods
We examined a dataset of 75,000 emergency department (ED) patient encounters from a single health system in Northeast Ohio who underwent nucleic acid amplification testing (NAAT) for chlamydia, gonorrhea, or trichomonas, or who received a urinalysis and urine culture. All patients were ≥18 years of age, and all encounters took place between April 18, 2014, and March 7, 2017. The analysis only included men receiving an ED diagnosis of epididymitis, orchitis, or both. We evaluated laboratory and demographic data using univariable and multivariable analyses.
Results
There were 1.3% (256/19,308) of men in the dataset diagnosed with epididymitis, orchitis, or both. Only 50.1% (130/256) of men diagnosed with epididymitis, orchitis, or both were tested for gonorrhea and chlamydia during their clinical encounter, and among those 13.8% (18/130) were positive. Chlamydia (12.3% [16/130]) was more common than both gonorrhea (3.1% [4/129]) and trichomonas (8.8% [3/34]) among men <35 years of age diagnosed with epididymitis, orchitis, or both. Only 62.1% of men diagnosed with epididymitis, orchitis, or both received a urine culture, of which 20.1% grew bacteria at ≥10,000 CFU/ml. E. coli (N= 20) was the most common bacteria growing in urine culture followed by Streptococcus (N= 3), Klebsiella (N= 2), Pseudomonas (N= 2), and Serratia (N= 2). Men diagnosed with epididymitis, orchitis, or both who had a positive urine culture were more likely to be ≥35 years of age, married, had higher urine white blood cells (WBCs), more urine bacteria, higher urine leukocyte esterase, more likely to have urine nitrite, and were less likely to be empirically treated for gonorrhea and chlamydia (P≤.03 for all).
Conclusions
In the ED, epididymitis, orchitis, or both are uncommonly diagnosed among patients undergoing genitourinary tract laboratory testing. Sexually transmitted infections (STIs) are common in men <35 years of age diagnosed with epididymitis, orchitis, or both, with chlamydia being most common. E. coli was the most common bacteria growing in urine culture.

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Review began 04/28/2021
Review ended 06/16/2021
Published 06/21/2021
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A Descriptive Analysis of Men Diagnosed With
Epididymitis, Orchitis, or Both in the Emergency
Department
Mason Bonner , Johnathan M. Sheele , Santiago Cantillo-Campos , Justin M. Elkins
1. Emergency Medicine, Mayo Clinic, Jacksonville, USA
Corresponding author: Mason Bonner, bonner.william@mayo.edu
Abstract
Introduction
Epididymitis and orchitis are illnesses characterized by pain and inflammation of the epididymis and testicle.
They represent the most common causes of acute scrotal pain in the outpatient setting. Epididymitis and
orchitis have both infectious and noninfectious causes, with most cases being secondary to the invasive
pathogens chlamydia, gonorrhea, and Escherichia coli (E.coli). The study's objective was to examine the
epidemiology and clinical characteristics of men diagnosed with epididymitis or orchitis in a United States
emergency department.
Methods
We examined a dataset of 75,000 emergency department (ED) patient encounters from a single health system
in Northeast Ohio who underwent nucleic acid amplification testing (NAAT) for chlamydia, gonorrhea, or
trichomonas, or who received a urinalysis and urine culture. All patients were ≥18 years of age, and all
encounters took place between April 18, 2014, and March 7, 2017. The analysis only included men receiving
an ED diagnosis of epididymitis, orchitis, or both. We evaluated laboratory and demographic data using
univariable and multivariable analyses.
Results
There were 1.3% (256/19,308) of men in the dataset diagnosed with epididymitis, orchitis, or both. Only
50.1% (130/256) of men diagnosed with epididymitis, orchitis, or both were tested for gonorrhea and
chlamydia during their clinical encounter, and among those 13.8% (18/130) were positive. Chlamydia (12.3%
[16/130]) was more common than both gonorrhea (3.1% [4/129]) and trichomonas (8.8% [3/34]) among men
<35 years of age diagnosed with epididymitis, orchitis, or both. Only 62.1% of men diagnosed with
epididymitis, orchitis, or both received a urine culture, of which 20.1% grew bacteria at ≥10,000 CFU/ml. E.
coli (N= 20) was the most common bacteria growing in urine culture followed by Streptococcus (N= 3),
Klebsiella (N= 2), Pseudomonas (N= 2), and Serratia (N= 2). Men diagnosed with epididymitis, orchitis, or both
who had a positive urine culture were more likely to be ≥35 years of age, married, had higher urine white
blood cells (WBCs), more urine bacteria, higher urine leukocyte esterase, more likely to have urine nitrite,
and were less likely to be empirically treated for gonorrhea and chlamydia (P≤.03 for all).
Conclusions
In the ED, epididymitis, orchitis, or both are uncommonly diagnosed among patients undergoing
genitourinary tract laboratory testing. Sexually transmitted infections (STIs) are common in men <35 years
of age diagnosed with epididymitis, orchitis, or both, with chlamydia being most common. E. coli was the
most common bacteria growing in urine culture.
Categories: Emergency Medicine, Urology, Public Health
Keywords: epididymitis, orchitis, epididymo-orchitis, chlamydia
Introduction
Epididymitis and orchitis are characterized by pain and inflammation of the epididymis and testicle,
respectively. They can occur together as epididymo-orchitis or independently. There are roughly 600,000
cases of epididymitis annually in the United States. It affects all age groups and represents the most common
cause of acute scrotal pain in the outpatient setting [1,2]. The etiology, diagnostic evaluation, and treatment
differ depending upon the patient's age [3,4].
Acute epididymitis is a disease isolated to the epididymis; however, it occurs in concert with orchitis in 47-
58% of cases [5,6]. Isolated orchitis without epididymis is quite uncommon and is typically caused by non-
sexually transmitted infections (STIs) such as the Coxsackie-B virus, mumps, or through the hematogenous
1 1 1 1
Open Access Original
Article DOI: 10.7759/cureus.15800
How to cite this article
Bonner M, Sheele J M, Cantillo-Campos S, et al. (June 21, 2021) A Descriptive Analysis of Men Diagnosed With Epididymitis, Orchitis, or Both in
the Emergency Department. Cureus 13(6): e15800. DOI 10.7759/cureus.15800

spread of bacteria [7]. Epididymo-orchitis typically begins as unilateral scrotal tenderness that worsens over
several days and can advance to include generalized and bilateral testicular tenderness, testicular swelling,
reactive hydrocele, dysuria/urethral syndromes, and overlying erythema [8,9]. Severe cases may present with
fever, nausea, and systemic symptoms. The pathophysiology of infectious epididymitis is still not
completely understood but may result from reflux of infected urine into the ejaculatory duct secondary to an
obstructed outlet [3,10]. Processes such as benign prostatic hypertrophy may play a role via outlet
obstruction in developing this disease [3,10].
Epididymitis, epididymo-orchitis, and orchitis are known to have both infectious and noninfectious causes,
and routine screening has only identified a bacterial cause in 25% of cases [10]. For men < 35 years of age,
the most common causes of epididymitis and epididymo-orchitis are chlamydia and gonorrhea [11,12]. Men
over 35 years of age with epididymitis are more likely to be infected with coliform bacteria, with E. coli being
the most common [13-15]. Other rare infectious causes of epididymitis include tuberculosis and brucellosis
[16-17]. Noninfectious causes of the disease include genitourinary trauma, iatrogenic bladder or urethral
instrumentation, amiodarone, and autoimmune illnesses such as sarcoidosis and Behçet syndrome [18-20].
There is a paucity of large-scale studies evaluating patients' clinical characteristics with epididymitis,
orchitis, or both in the emergency department (ED). This study aims to examine the epidemiology and
clinical characteristics of men with epididymitis, orchitis, or both in the ED, specifically those with and
without a sexually transmitted infection (STI) or a urinary tract infection (UTI).
Materials And Methods
The study received institutional review board approval from University Hospitals (UH). The UH information
technology (IT) team created a database consisting of 75,000 UH emergency department (ED) patient
encounters in Northeast Ohio between April 18, 2014, to March 7, 2017. Data were extracted from the UH
electronic medical record using a custom structured query language (SQL) in SQL Server Management
Studio (SSMS). All patients were ≥18 years of age, seen in a UH ED, and underwent testing for gonorrhea,
chlamydia, trichomonas, or had a urinalysis and urine culture performed. We used the existing dataset to
explore our clinical question and only included men in the analysis. Analyses from the dataset have
previously been published [21-25].
Men with epididymitis, orchitis, or both had been combined into a single variable by UH IT when the dataset
was created using the following ED International Classification of Diseases, Ninth Revision (ICD-9),
and International Statistical Classification of Diseases, Tenth Revision (ICD-10) discharge codes: N45,
N45.1, N45.4, 604.0, 604.90, or 604.99. Patients were diagnosed with a urinary tract infection (UTI) if they
had one of the following ED discharge (ICD-9, -10) codes: N30.0, N30.00, N30.01, N30, N30.9, N30.90,
N39.0, O03.38, O03.88, O04.88, O08.83, O23.10, O23.40, O86.2, O86.20, O86.22, O86.29, 595.0, 595.89,
595.9, 599.0, 639.8, 646.60, or 646.64. Men were diagnosed with prostatitis if they had an (ICD-9, -10) code
of N41, N41.0, N41.8, N41.9, N42, 601.0, 601.8, or 601.9. Patients were infected with N gonorrhoeae and C
trachomatis if they had a positive nucleic acid amplification test (NAAT) (APTIMA, Hologic). Patients were
infected with Trichomonas vaginalis if the organism was seen on genital wet prep, reported on the
urinalysis, or had a positive NAAT (APTIMA, Hologic). Patients had to have a negative T vaginalis NAAT to
be classified as uninfected. Trace urine protein was categorized as 0.5 mg/dL for the analysis. To account for
differences in how urine red blood cells (RBCs) and white blood cells (WBCs) were reported from the
laboratory, all urine RBCs and WBCs >100 cells/HPF were recorded as 101, and for any ranges of urine RBCs
and WBCs, the mean of that range was used for the analysis. A urine culture growing ≥10,000 colony forming
units (CFU)/mL was considered positive, and <10,000 CFU/mL was negative. Men given ceftriaxone or
cefixime plus azithromycin or an outpatient prescription for doxycycline were considered treated for
gonorrhea and chlamydia. Missing and erroneous variables were not included in the analysis.
Data analysis
Continuous variables were summarized as the median and interquartile range (IQR) and were analyzed using
the Wilcoxon rank-sum test. Categorical variables were summarized as counts and percentages and analyzed
using the Chi-square test. Unless otherwise stated all multivariable logistic regression accounted for: age
(years), black race vs. other race, urine leukocyte esterase (0-3+), urine WBCs (0-101), tested for gonorrhea
and chlamydia (vs not), urine protein (0, 0.5 (trace), 1+, 2+, or 3+), urine bacteria (0-4+), urine RBCs (0-101),
urine urobilinogen (0, 2, 4, 8, or 12), urine blood 0-3+), and marital status (married, single, or divorced,
widowed, or separated). Odds ratios and 95% confidence intervals were calculated, and a P-value of <.05 was
considered statistically significant. The analysis was conducted using JMP Pro 14 (SAS Institute Inc).
Results
Epididymitis, orchitis, or both were diagnosed in 256/19,308 (1.3%) ED encounters. The clinical
characteristic for men in the dataset with and without epididymitis, orchitis, or both are summarized in
Table 1. On univariable analysis, men with epididymitis, orchitis, or both, compared to men in the dataset
without these diagnoses, were younger, less likely to arrive by emergency medical services (EMS), less likely
to be admitted to the hospital, were more likely to be single, less likely to have a primary care physician, and
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 2 of 13

had higher triage pain scores (P≤.002). On regression analysis, men with epididymitis, orchitis, or both were
significantly younger, less likely to arrive by EMS, less likely to be admitted to the hospital, less likely to
have a primary care physician, have higher ED triage pain scores, and have lower emergency severity index
(ESI) scores (P≤.006 for all). On univariable analysis, there were significant differences in the urinalysis
between those with and without epididymitis, orchitis, or both, including the presence of bacteria, blood,
protein, RBCs, urobilinogen, WBCs (P≤.02). On regression analysis, only urine WBCs were significantly
higher for those with epididymitis, orchitis, or both (P=.03). Men with epididymitis, orchitis, or both were
more likely tested for gonorrhea and chlamydia and less likely to be diagnosed with a UTI (P≤.001).
+Epididymitis
and/or orchitis
(N=256)
No epididymitis or orchitis
(N=19,052
p-
value
Adjusted OR (95% CI) for
having epididymitis and/or
orchitis
Adjusted
p-value
Age 35 (25,53) 61 (38,77) .14 (.97-.99)
Black race, % 57% (145/253) 48% (8,999/18,957) .002 .88 (.59-1.31) .52
Arrived by EMS (vs. not) 5% (12/254) 38% (7,229/18,812) .12 (.06-.26)
Admitted from the ED 17% (43/256) 47% (8,859/19,052) .50 (.32-.77) .002
Marital status Single Married
Divorced, widowed, separated
67% (171/255)
25% (63/255) 8%
(21/255)
44% (8,295/18,934) 40%
(7,489/18,934) 17%
(3,150/18,934)
NA NA
+ Primary care physician 25% (63/256) 42% (8,095/19,052) .55 (.36-.84) .006
Triage pain scale 5 (0,7) N= 48 0 (0,5) N= 8,468 1.17 (1.06-1.28) .002
Hour of ED visit 14 (10,18) 14 (10,18) .44 1.00 (.98-1.03) .78
ED encounter over weekend (vs
weekday) 25% (64/256) 28% (5,277/19,052) .34 .87 (.60-1.27) .48
Emergency severity index (ESI) 3 (3,3) N= 251 3 (3,3) N=18,387 .14 .57 (.43-.74)
Urine source: Clean catch Straight
catheter Old bladder catheter
Unknown
94% (124/132) 2%
(3/132) 4% (5/132)
66% (7,924/11,983) 6%
(749/11,983) 28%
(3,310/11,983)
NA NA
Urine bacteria 0 (0,1) N= 149 1 (0,2) N= 12,178 .002 .91 (.77-1.08) .28
Urine blood 0 (0,1) N= 231 0 (0,2) N= 15,814 .97 (.78-1.21) .79
Urine leukocyte esterase 0 (0,2) N= 233 0 (0,2) N= 15,902 .28 1.16 (.94-1.44) .17
Urine nitrite positive (vs negative) 7% (16/234) 8% (1,241/16,122) .62 1.46 (.20-.82) .20
Urine protein 0 (0,1) N= 234 1 (0,2) N= 16,060 .81 (.65-1.01) .06
Urine RBCs 3 (3,13) N= 151 3 (3,36) N= 12,166 .02 1.00 (.99-1.01) .55
Urine Urobilinogen 0 (0,2) N= 234 0 (0,0) N= 16,128 .02 1.04 (.95-1.14) .44
Urine WBCs 18 (2.5,101) N= 151 13 (3,45) N= 12,164 1.01 (1.00-1.01) .03
Urine culture ≥10,000 CFU/mL, % 20% (32/159) 22% (3,176/14,589) .70 1.25 (.73-2.12) .42
Tested for gonorrhea and chlamydia 51% (130/256) 16% (3,002/19,052) 3.94 (2.47-6.29)
Diagnosed with a UTI 5% (12/256) 13% (2,527/19,052) .27 (.14-.50)
Diagnosed with prostatitis 0% (0/256) .4% (77/19,052) .31 NA NA
TABLE 1: Demographic and clinical characteristics of men with and without epididymitis or
orchitis.
Epididymitis, orchitis, or both compared to men with UTI
There were 2,539/19,308 (13.1%) men in the dataset diagnosed with a UTI. Among those men diagnosed with
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 3 of 13

a UTI and no epididymitis or orchitis, 93% (2,362/2,527) had a urine culture performed, and 51%
(1,194/2,362) grew bacteria at ≥10,000 CFU/mL. Men with epididymitis, orchitis, or both, when compared to
men diagnosed with a UTI but not epididymitis or orchitis, were younger, more likely Black, less likely
married, had fewer urine WBCs, fewer urine RBCs, fewer urine bacteria, less urine protein, less urine
leukocyte esterase, and less urine nitrite (P<.001 for all) (Table 2). On multivariable analysis, those with
epididymitis, orchitis, or both were significantly younger, had fewer urine bacteria, and had lower urine
leukocyte esterase than men diagnosed with a UTI (P<.001). There were 146/2,527 (5.8%) of men diagnosed
with a UTI but not with epididymitis or orchitis tested for gonorrhea and chlamydia. Among these, 41.8%
(61/146) were positive for gonorrhea, chlamydia, or both. In comparison, 51.6% (126/244) of men with
epididymitis, orchitis, or both were not diagnosed with a UTI and underwent testing for gonorrhea and
chlamydia. Among these, 12.7% (16/126) were positive for either or both infections.
+Epididymitis and/or
orchitis (N=256)
+UTI and no epididymitis
or orchitis (N=2,527)
p-
value
Adjusted OR (95% CI) for those with
epididymitis and/or orchitis
Adjusted
p-value
Age 35 (25, 53) 71 (54,83) <
.001> .98 (.97-.99) < .001>
Black race, % 57% (145/253) 40% (1015/2522) <
.001> 1.13 (.74-1.72) .57
Marital status (% married) 25% (63/255) 45% (1126/2513) <
.001> NA NA
Urine WBCs 18 (3,101) N= 151 60 (13,101) N= 2442 <
.001> 1.00 (1.00-1.01) .33
Urine RBCs 3 (3,13) N= 151 13 (3,37) N= 2449 <
.001> .99 (.99-1.00) .21
Urine bacteria 0 (0,1) N= 149 1 (1,3) N= 2479 <
.001> .74 (.62-.88) < .001>
Urine protein 0 (0,1) N= 234 1 (1,3) N= 2475 <
.001> .89 (.71-1.12) .34
Urine leukocyte esterase 0 (0,2) N= 233 3 (1,3) N= 2391 <
.001> .69 (.55-.85) < .001>
Urine nitrite 7% (16/234) 22% (536/2492) <
.001> .93 (.51-1.68) .80
Urine culture growing
≥10,000 CFU/mL bacteriuria 20% (32/159) 51% (1194/2362) <
.001> 1.10 (.66-1.81) .72
+Gonorrhea 3% (4/129) 24% (35/145) <
.001> .26 (.08-.86) .03
+Chlamydia 12% (16/130) 24% (35/146) .01 .88 (.40-1.92)* .75*
+Trichomonas 9% (3/34) 6% (2/31) .72 .96 (.04-21.82)* .98*
+Any STI 15% (20/130) 43% (63/146) <
.001> .48 (.22-1.02)* .05*
TABLE 2: Comparison of men with epididymitis and/or orchitis and men diagnosed with a UTI.
NG: Neisseria gonorrhoeae, CT: Chlamydia trachomatis,
Epididymitis, orchitis, or both in men with and without concurrent UTI
There were 4.7% (N=12) men diagnosed with epididymitis, orchitis, or both and a concurrent UTI; however,
only eight received a urine culture, and of those four grew bacteria at ≥10,000 CFU/mL. Among the 12 men
with epididymitis, orchitis, or both and diagnosed with a UTI, one had chlamydia, one had gonorrhea, and
none were positive for trichomonas. Men with epididymitis, orchitis, or both and a UTI diagnosis had higher
urine WBCs, higher median urine blood, higher median leukocyte esterase, proteinuria, and were more likely
to have a positive urine culture (P≤.03) (Table 3).
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 4 of 13

+Epididymitis and/or orchitis and +UTI
(N=12)
+Epididymitis and/or orchitis and -UT I
(N= 244)
p-
value
Age 51 (29,62) 35 (25,52) .22
Black race, % 50% (6/12) 58% (139/241) .60
Marital status (% married) 50% (6/12) 23% (57/243) .09
Urine WBCs 76 (36,101) 13 (3,101) N= 139 .01
Urine RBCs 9 (3,43) 3 (2,13) N= 139 .08
Urine blood 1 (1,2) N= 11 0 (0,1) N= 220 .002
Urine bacteria 1 (0,1) 0 (0,1) N= 137 .14
Urine leukocyte esterase 3 (2,3) N= 11 0 (0,2) N= 222
Urine nitrite 0% (0/12) 7% (16/222) .34
Urine protein 2 (0,2) 0 (0,1) N= 222 .004
Urine culture growing ≥10,000 CFU/mL
bacteriuria 50% (4/8) 19% (28/151) .03
Tested for gonorrhea and/or chlamydia 33% (4/12) 52% (126/244) .22
+Gonorrhea 25% (1/4) 2% (3/125) .01
+Chlamydia 25% (1/4) 12% (15/126) .43
+Trichomonas 0% (0/1) 9% (3/33) .75
+ Any STI 50% (2/4) 14% (18/126) .05
TABLE 3: Comparison of men with epididymitis and/or orchitis and diagnosed with a UTI
compared to those diagnosed with epididymitis and/or orchitis and without concurrent UTI.
Epididymitis, orchitis, or both and urine cultures
There were 62.1% (N=159) men diagnosed with epididymitis, orchitis, or both that had a urine culture
performed, of which 20.1% (32/159) grew bacteria at ≥10,000 CFU/mL (Table 4). The most common bacterial
genus identified in men with epididymitis, orchitis, or both were: Escherichia (N=20), Streptococcus (N=3),
Klebsiella (N=2), Pseudomonas (N=2), Serratia (N=2), Staphylococcus (N=1), Lactobacillus (N=1),
Enterococcus (N=1). No patient with epididymitis, orchitis, or both and a positive urine culture also had a
positive test for gonorrhea, chlamydia, or trichomonas. On univariable analysis, men with epididymitis,
orchitis, or both and positive urine culture were significantly older, more likely married, had higher urine
WBCs, more urine RBCs, more urine blood, more urine bacteria on urinalysis, higher protein, and were more
likely to be nitrite positive (P≤.04 for all) (Table 4). On multivariable regression analysis, men with
epididymitis, orchitis, or both and positive urine culture were significantly older, more likely to be Black, had
higher urine bacteria, and more likely to have positive nitrite urine (P≤.02 for all).
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 5 of 13

+Epididymitis and/or orchitis
and +urine culture (N=32)
+Epididymitis and/or orchitis
and -urine culture (N=127)
p-
value
Adjusted OR (95% CI) for those
with a positive urine culture
Adjusted
p-value
Age 65 (47,77) 37 (25, 53) 1.08 (1.03-1.15) .004
Black race, % 63% (20/32) 47% (59/125) .12 10.34 (1.42-74.97) .02
Marital status (%
married) 50% (16/32) 27% (34/126) .04 NA NA
Urine WBCs 101 (41,101) N= 31 13 (3,76) N= 78 1.03 (.99-1.06) .08
Urine RBCs 11 (3,24) N = 31 3 (3,13) N= 78 .01 1.00 (.97-1.02) .86
Urine blood 1 (1,2) 0 (0,1) N= 120 .62 (.25-1.36) .26
Urine bacteria 1 (1,3) N= 31 0 (0,1) N=77 2.31 (1.38-4.22) .003
Urine protein 1 (0,2) 0 (0,1) N= 122 .003 .59 (.21-1.49) .28
Urine leukocyte
esterase 3 (2,3) 0 (0,2) N= 121 1.50 (.65-3.67) .35
Urine nitrite 34% (11/32) 1% (1/122) 22.99 (1.50-353.19) .02
Tested for gonorrhea
and/or chlamydia 31% (10/32) 32% (41/127) .91 2.10 (.40-11.16) .38
+Gonorrhea 0% (0/10) 5% (2/41) .48 NA NA
+Chlamydia 0% (0/10) 15% (6/41) .20 NA NA
+Trichomonas 0% (0/3) 10% (1/10) .57 NA NA
+Any STI 0% (0/10) 19% (8/42) .13 NA NA
TABLE 4: Men with epididymitis and/or orchitis and a positive urine culture compared to men with
epididymitis and/or orchitis and a negative urine culture.
Epididymitis, orchitis, or both with a positive urine culture or an STI
Men with epididymitis, orchitis, or both and positive urine culture were significantly older, more likely to be
married, had higher urine WBCs, more urine bacteria, higher urine leukocyte esterase, higher urine nitrite,
and less likely to be treated for gonorrhea and chlamydia than those with epididymitis, orchitis, or both and
positive for an STI (P≤.03 for all) (Table 5).
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+Epididymitis and/or orchitis and +urine culture
and -STI (N=32)
+Epididymitis and/or orchitis and -urine culture
and +STI (N=20)
p-
value
Age 65 (47,77) N= 32 26 (21,30) N= 20 <
.001>
Black race, % 63% (20/32) 75% (15/20) .35
Marital status (% married) 50% (16/32) 0% (0/20) <
.001>
Urine WBCs 101 (41,101) 37 (13,101) .03
Urine RBCs 11 (3,24) 4 (3,19) .23
Urine bacteria 1 (1,3) 0 (0,1) .001
Urine leukocyte esterase 3 (2,3) 1 (0,2) <
.001>
Urine nitrite 34% (11/32) 0% (0/18) .005
Treated for gonorrhea and
chlamydia 28% (9/32) 80% (16/20) <
.001>
TABLE 5: Men with epididymitis and/or orchitis and positive urine culture and no STIs compared
to men with epididymitis and/or orchitis and a negative urine culture but infected with gonorrhea,
chlamydia, and/or trichomonas.
Epididymitis, orchitis, or both who were and were not tested for
gonorrhea and chlamydia
There were 130 men with epididymitis, orchitis, or both tested for gonorrhea and chlamydia. Among those
with epididymitis, orchitis, or both, there were 3.1% (4/129) infected with gonorrhea, 12.3% (16/130)
infected with chlamydia, and 6.3% (2/32) infected with trichomonas. Those tested for gonorrhea and
chlamydia were significantly younger, more likely Black, unmarried, had fewer urine bacteria and had less
urine leukocyte esterase (P≤.04 for all) (Table 6).
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 7 of 13

+Epididymitis and/or orchitis and tested for
gonorrhea and chlamydia (N=130)
+Epididymitis and/or orchitis and not tested for
gonorrhea and chlamydia (N=126)
p-
value
Age 29 (23,40) N= 130 45 (30,63) N= 126
Black race, % 71% (92/129) 43% (53/124)
Marital status (% married) 15% (19/105) 35% (44/66)
Urine WBCs 13 (3,76) N= 69 36 (3,101) N= 82 .24
Urine RBCs 3 (1,13) N= 69 3 (3, 15) N= 82 .10
Urine bacteria 0 (0,1) N= 68 1 (0,2) N= 81 .04
Urine leukocyte esterase 0 (0,1) N= 119 1 (0,3) N= 114 .009
Urine nitrite 4% (5/119) 10% (11/115) .10
Urine culture growing ≥10,000
CFU/mL bacteriuria 20% (10/51) 20% (22/108) .91
+Gonorrhea 3% (4/129) NA NA
+Chlamydia 12% (16/130) NA NA
+Trichomonas 6% (2/32) 50% (1/2) NA
TABLE 6: Comparison of those with epididymitis and/or orchitis who were and were not tested for
gonorrhea and chlamydia.
Men in the dataset who tested positive for an STI and who either had or
did not have epididymitis, orchitis, or both
The only significant difference between men in the dataset that tested positive for an STI and did or did not
have concurrent epididymitis, orchitis, or both was that the latter were less likely to be of the Black race
(P=004) (Table 7).
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+Epididymitis and/or orchitis and positive for
gonorrhea, chlamydia, and/or trichom onas (N=20)
+Gonorrhea, chlamydia, and/or tricho monas but no
epididymitis and/or orchitis (N=804)
p-
value
Age 26 (21,30) 24 (21,30) .64
Black race, % 75% (15/20) 93% (742/801) .004
Marital status (%
married) 0% (0/20) 4% (36/301) .56
Urine WBCs 37 (13,101) N= 17 39 (13,101) N= 351 .91
Urine RBCs 4 (3,19) N= 17 3 (2,8) N= 348 .23
Urine bacteria 0 (0,1) N= 17 0 (0,1) N= 350 .64
Urine leukocyte
esterase 1 (0,2) N= 18 1 (0,3) N= 420 .67
Diagnosed with a
UTI 10% (2/20) 8% (63/804) .72
Treated for
gonorrhea and
chlamydia
80% (16/20) 83% (667/804) .73
TABLE 7: Men infected with gonorrhea, chlamydia, and/or trichomonas who either had or did not
have epididymitis and/or orchitis.
Epididymitis, orchitis, or both with and without an STI
Overall, 24.3% (N=761/3132) of men in the dataset tested positive for gonorrhea or chlamydia, and this
compares with a rate of 13.8% (18/130) for those diagnosed with epididymitis, orchitis, or both. There were
15.4% (20/130) men with epididymitis, orchitis, or both that tested positive for gonorrhea, chlamydia, or
trichomonas. Among those with epididymitis, orchitis, or both and positive for an STI, the rates of infection
were 21% (4/20) for gonorrhea, 84% (16/20) for chlamydia, and 60% (3/5) for trichomonas. On univariable
analysis, men with an STI were younger and had higher urine WBCs and more leukocyte esterase (P≤.02 for
all) (Table 8).
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 9 of 13

+Epididymitis and/or orchitis and positive for
gonorrhea, chlamydia, and/or trichom onas (N=20)
+Epididymitis and/or orchitis and neg ative for
gonorrhea, chlamydia, and trichomon as (N=110)
p-
value
Age 26 (21,30) 31 (23,44) .02
Black race, % 75% (15/20) 71% (77/109) .69
Marital status (% married) 0% (0/20) 17% (19/110) .06
Urine WBCs 37 (13,101) N= 17 13 (3,76) N= 53 .02
Urine RBCs 4 (3,19) N= 17 3 (1,12) N= 53 .19
Urine leukocyte esterase 1 (0, 2) N= 18 0 (0,1) N= 102 .003
Urine nitrite 0% (0/18) 5% (5/102) .34
Urine culture growing
≥10,000 CFU/mL
bacteriuria
0% (0/8) 23% (10/44) .13
Treated for gonorrhea and
chlamydia 80% (16/20) 63% (69/110) .14
+Gonorrhea 21% (4/19) 0% (0/110) NA
+Chlamydia 84% (16/19) 0% (0/110) NA
+Trichomonas 60% (3/5) 0% (0/28) NA
TABLE 8: Men with epididymitis and/or orchitis and infected with a STI compared to men with
epididymitis and/or orchitis and testing negative for a STI.
Epididymitis, orchitis, or both in those treated or not treated for
gonorrhea and chlamydia
There were 44.5% (114/256) of men diagnosed with epididymitis, orchitis, or both treated for gonorrhea and
chlamydia in the ED. Among those empirically treated, 0% (0/44) had gonorrhea, and 15% (13/85) had
chlamydia, which compared to those not empirically treated, of which 5% (4/85) were positive for gonorrhea
and 7% (3/45) for chlamydia. On univariable analysis, men who received treatment for epididymitis, orchitis,
or both were significantly younger, more likely Black race, and less likely to be married (P<.001 for all) (Table
9).
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 10 of 13

+Epididymitis and/or orchitis and trea ted for
gonorrhea and chlamydia (N=114)
+Epididymitis and/or orchitis and not treated for
gonorrhea and chlamydia (N=142)
p-
value
Age 29 (23,39) 45 (29,61)
Black race, % 77% (88/114) 41% (57/139)
Marital status (% married) 14% (16/113) 33% (47/142)
Urine WBCs 13 (3,76) N= 67 28 (3,101) N= 84 .79
Urine bacteria 0 (0,1) N= 67 1 (0,1) N= 82 .13
Urine leukocyte esterase 0 (0,1) N= 102 0 (0,2) N= 131 .68
Urine nitrite 8% (8/103) 6% (8/131) .62
Urine culture growing ≥10,000
CFU/mL bacteriuria 83% (43/52) 79% (84/107) .54
+Gonorrhea 0% (0/44) 5% (4/85) .14
+Chlamydia 15% (13/85) 7% (3/45) .15
+Trichomonas 7% (2/28) 17% (1/6) .46
+Any STI 19% (16/85) 9% (4/45) .14
TABLE 9: Men with epididymitis and/or orchitis that were treated or not treated for gonorrhea and
chlamydia.
Epididymitis, orchitis, or both and marital status
There were 25% (63/256) married men with epididymitis, orchitis, or both, and 19 were tested for STIs, of
which all results were negative. There were six married men with epididymitis, orchitis, or both diagnosed
with a UTI, all had urine cultures performed, and four grew bacteria ≥10,000 CFU/mL.
Epididymitis, orchitis, or both in those <35 and ≥35 years of age
Among men with epididymitis, orchitis, or both, 48.4% (124/256) were <35 years of age. Among those <35
years of age, 66.9% (83/124) were tested for gonorrhea and/or chlamydia, of which (19.3% 16/83) were
positive for at least one infection, including two with trichomonas, three with gonorrhea, and 14 with
chlamydia. 36.6% (15/41) of patients <35 years of age that were not tested for gonorrhea and chlamydia were
empirically treated for the infection. Among men <35 years of age, there were 47.6% (59/124) that had a
urine culture performed, but only 5.1% (3/59) grew bacteria ≥10,000 CFU/mL. Five men <35 years of age were
concurrently diagnosed with a UTI and epididymitis, orchitis, or both, and 0% (0/2) had a positive urine
culture ≥10,000 CFU/mL.
In the dataset, 52% (132/256) of men ≥35 years of age were diagnosed with epididymitis, orchitis, or both.
There were 22% (7/32) concurrently diagnosed with a UTI, and of these, 67% (4/6) had a positive urine
culture ≥10,000 CFU/mL. There were 47 men ≥35 years of age tested for gonorrhea and chlamydia, with 4%
(2/47) positive for infection, one patient having both gonorrhea and chlamydia, one having only chlamydia,
and only one who had trichomonas. There were 16% (14/85) not tested for gonorrhea or chlamydia and ≥35
years of age that were empirically treated for gonorrhea and chlamydia.
Discussion
Epididymitis, orchitis, or both were infrequently diagnosed in men undergoing genitourinary tract
laboratory testing in the ED. Similar to previously reported, we found an association between STIs and the
patient's age [5,11-14]. For men <35 years of age, STIs are more commonly causing epididymitis, orchitis, or
both, with chlamydia being the common pathogen. However, an STI was identified in only 15% of patients
with epididymitis, orchitis, or both who underwent testing. STIs were present in men ≥35 years of age;
however, they were less frequent, and testing occurred less often in this age group. Testing younger men
with epididymitis, orchitis, or both may be because STIs' overall prevalence is higher in younger adults or to
age-related bias by the providers.
E.coli was the most frequent bacteria found in urine culture among men diagnosed with epididymitis,
orchitis, or both and was more common in men ≥35 years of age. However, only 20.1% of urine cultures were
2021 Bonner et al. Cureus 13(6): e15800. DOI 10.7759/cureus.15800 11 of 13

positive. Men ≥35 years of age with epididymitis, orchitis, or both were more likely to be concurrently
diagnosed with a UTI and less likely to be tested for an STI-potentially be due to men in this age group being
less likely to engage in high-risk sexual behavior and age-related changes such as outlet obstruction from
benign prostatic hypertrophy [3,5].
Prior studies have found that the sexual history is frequently not well documented in patients with
epididymitis, despite treatment guidelines that suggest patients continue to undergo evaluation for sexually
transmitted diseases [26-29]. In our study, 66.9% of patients with epididymitis, orchitis, or both under 35
years of age were tested for STI, 12% were treated for STIs but never tested, and 20% were not tested or
treated for STI. Treatment guidelines published by the CDC recommend empiric coverage for sexually
transmitted disease in all men with epididymitis ≤35 years of age [4,10]. Sexually transmitted infections also
occur in older populations, and high-risk sexual behavior could influence the decision to treat empirically for
STI.
Limits
Data was collected from a single health system in Northeast Ohio, and results may not be generalizable.
There was no history and physical exam information available in the dataset. The dataset did not
differentiate between acute and chronic epididymitis and orchitis. Patients receiving ceftriaxone or cefixime
plus azithromycin or an outpatient prescription for doxycycline could have been treated for infections other
than gonorrhea and chlamydia. Because the epididymitis and orchitis diagnoses were combined within the
dataset before we examined the data, those patients with only epididymitis or orchitis were not
differentiated from those who had epididymitis-orchitis. There was significant variability in infectious
screening offered to patients. The study was retrospective, and not all patients with epididymitis, orchitis, or
both underwent testing for STIs and received a urine culture. Few men underwent testing for T vaginalis. The
STI sampling method (e.g., urethral swab vs. urine sample) may have influenced the sensitivity of diagnosing
an STI by NAAT.
Conclusions
Within our dataset of men in the ED undergoing genitourinary tract laboratory testing, the prevalence of
epididymitis, orchitis, or both was only 1.3%. For men <35 years of age, and STI was found in 15.4%, with
chlamydia being the most frequently identified STI. There were few men ≥35 years of age tested for an STI,
and most of those tested were negative. Only 20.1% of urine cultures from men with epididymitis, orchitis,
or both grew bacteria at ≥10,000 CFU/mL. E. coli was the most common bacteria isolated in urine culture.
Age ≥35 years and being married were associated with being diagnosed with a UTI and epididymitis, orchitis,
or both. Age <35 years, Black race, and being unmarried were associated with an increased likelihood of
being tested and treated for an STI.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. University Hospitals
issued approval 18-008945. University Hospitals Health system issued approval for the clinical study upon
which this manuscript was written. Animal subjects: All authors have confirmed that this study did not
involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure
form, all authors declare the following: Payment/services info: All authors have declared that no financial
support was received from any organization for the submitted work. Financial relationships: All authors
have declared that they have no financial relationships at present or within the previous three years with
any organizations that might have an interest in the submitted work. Other relationships: All authors have
declared that there are no other relationships or activities that could appear to have influenced the
submitted work.
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