Autoimmune Orchitis – Causes, Symptoms, Treatment

Autoimmune orchitis defined as the inflammation of the testicle unilaterally or bilaterally usually caused by viruses and bacteria inflammatory infiltrates in the testis (orchitis), epididymis (epididymitis), and vas deferens (vasitis) is a relevant cause of decreased fecundity in males, and it is defined as direct aggression to the testis with the concomitant presence of anti-sperm antibodies (ASA). The presence of these specific antibodies has been observed in approximately 5-12% of infertile male partners. Primary autoimmune orchitis is defined by isolated infertility with ASA but without evidence of systemic disease. Secondary causes of orchitis and/or testicular vasculitis are uniformly associated with autoimmune diseases, mainly in primary vasculitides such as polyarteritis nodosa, Beh√ßet’s disease, and Henoch-Sch√∂nlein purpura.

Autoimmune orchitis is characterized by testis inflammation and the presence of specific anti-sperm antibodies (ASA). It is classified into two categories. Primary autoimmune orchitis is defined by infertility and asymptomatic orchitis associated with ASA (100%) directed to the basement membrane of seminiferous tubules in infertile men, without any systemic disease and usually asymptomatic. Secondary autoimmune orchitis is characterized by symptomatic orchitis and/or testicular vasculitis associated with a systemic autoimmune disease, particularly vasculitis. These patients typically demonstrate testicular pain, erythema, and/or swelling. ASA in secondary autoimmune orchitis has been reported in up to 50% of patients, especially in systemic lupus erythematosus patients.

Causes of Autoimmune Orchitis

Various bacteria and viruses cause orchitis.

  • Orchitis in young patients is usually viral, with mumps and rubella being the most common causes. Reports exist of cases of orchitis have after the measles, mumps, and rubella (MMR) vaccine.
  • Other viruses include coxsackievirus, varicella, echovirus, and cytomegalovirus.
  • Bacterial infections of the prostate and urinary tract infection can cause orchitis. Common causes of bacterial orchitis include¬†Escherichia coli,¬†Klebsiella pneumonia,¬†Pseudomonas aeruginosa, and¬†Staphylococcus¬†and¬†Streptococcus¬†species.
  • Bacteria that can cause sexually transmitted infections can also cause orchitis in sexually active males. Common organisms are Neisseria gonorrhoeae,¬†Chlamydia trachomatis, and¬†Treponema pallidum
  • Mycobacterium avium¬†complex,¬†Cryptococcus neoformans,¬†Toxoplasma gondii,¬†Haemophilus parainfluenzae, and¬†Candida albicans¬†have been reported to cause orchitis in immunocompromised patients.

Classification of human epididymitis and orchitis according to etiological factors and pathomechanisms.

Etiology Main factors Pathomechanisms Clinical manifestation
Microorganisms
  • Bacteria

  • Uropathogens (Escherichia coli, Enterobacteriaceae spp. and others); sexually transmitted infections (Chlamydia trachomatis,¬†Neisseria gonorrhoeae¬†and others)

Ascending, canalicular infection Epididymitis/Epididymo-orchitis
Mycobacterium tuberculosis, M. leprae, Treponema pallidum, Brucella spp. Canalicular and/or hematogenous infection
  • Orchitis (predominantly granulomatous),

  • Epididymitis

  • Viruses

  • mumps virus, Coxsackie virus types, Epstein-Barr, influenza, varicella, human immunodeficiency viruses, and others

Hematogenous infection Orchitis
Adenovirus, Enterovirus Epididymitis
  • Fungi

  • Candida albicans,¬†Histoplasma capsulatum

Ascending, canalicular infection Epididymitis
  • Parasites

  • Trichomonas vaginalis

Epididymitis
Schistosoma spp., Filariasis
Chemical noxae Drugs (e.g. Amiodarone); heavy metals (e.g. mercury compounds) ?
  • Epididymitis,

  • Orchitis

Physical factors Genital trauma, vasectomy Obstruction Chronic Epididymitis
Unknown Systemic disease Morbus Behcet, systemic lupus erythematosus, Schönlein-Henoch purpura, and other vasculitic disorders Autoimmune inflammation
  • Orchitis,

  • Epididymitis

‚ÄėIdiopathic‚Äô Autoimmune inflammation?
  • Idiopathic epididymitis

  • Idiopathic granulomatous orchitis

There are also reports of orchitis caused by autoimmunity, which can classify as primary and secondary.

Symptoms of Autoimmune Orchitis

Orchitis signs and symptoms usually develop suddenly and can include:

  • Swelling in one or both testicles
  • Pain ranging from mild to severe
  • Fever
  • Nausea and vomiting
  • General feeling of unwellness (malaise)

The terms “testicle pain” and “groin pain” are sometimes used interchangeably. But groin pain occurs in the fold of skin between the thigh and abdomen ‚ÄĒ not in the testicle. The causes of groin pain are different from the causes of testicle pain.

Diagnosis of Autoimmune Orchitis

The patient usually presents with acute onset of testicular pain, which may initially involve one testis, and then may spread to include the whole scrotum. The patient may also complain of fever accompanied by malaise, fatigue, and chills.

  • Physical Examination findings – may include testicular enlargement, tenderness, and induration. Scrotal edema and erythema may also be present. Epididymis may also be enlarged if orchitis is accompanied with epididymitis. Cremasteric reflex is normal in affected individuals. Mumps orchitis may present with bilateral parotid enlargement and usually present 4 to 8 days after onset of parotitis.
  • STI screen –¬†If you have discharge from your urethra, a narrow swab is inserted into the end of your penis to obtain a sample of the discharge. The sample is checked in the laboratory for gonorrhea and chlamydia. Some STI screens are done with a urine test.
  • Urine test –¬†A sample of your urine is analyzed to see if anything’s abnormal.
  • Ultrasound –¬†This imaging test is the one most commonly used to assess testicular pain. Ultrasound with color Doppler can determine if the blood flow to your testicles is lower than normal ‚ÄĒ indicating torsion ‚ÄĒ or higher than normal, which helps confirm the diagnosis of orchitis.

Treatment of Autoimmune Orchitis

In an emergency, physicians must distinguish between torsion and inflammation of the testis. Antibiotics are not necessary for viral causes of the disease, supportive therapies such as bed rest, antipyretics, analgesics, scrotal support, and hot or cold packs for analgesia are advisable.

  • Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve)
  • Antibiotics should start empirically based on the likely pathogens according to age and sexual history.
  • If there is suspicion of an enteric bacteria is suspected, then fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) for 10 to 14 days are the preferred drugs. Trimethoprim-sulfamethoxazole is also an option for these pathogens.
  • If there is suspicion of a sexually transmitted pathogen, then treatment should consist of ceftriaxone 250 mg single shot intramuscularly and doxycycline 100 mg twice daily for 10 to 14 days. An azithromycin is also an option in place of doxycycline.
  • Most people with viral orchitis start to feel better in three to 10 days, although it can take several weeks for the scrotal tenderness to disappear.

Sexual partners of the patient with sexually transmitted pathogens should receive treatment. The inability to take oral antibiotics, signs of sepsis and failure of previous outpatient therapy should warrant inpatient therapy.

References

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