EAU 2009: Urologists Get a Failing Grade at Managing Epididymo-Orchitis in Sexually Active Young Men

Fran Lowry

April 03, 2009

March 27, 2009 (Stockholm, Sweden) — The management by urologists of young men presenting with acute epididymo-orchitis leaves much to be desired, according to a study that looked at the way the men were treated and their outcomes in 4 British teaching hospitals.

"The management fell markedly short of the recommended European Association of Urology [EAU] guidelines," Joshua Phillips, MD, of Sandwell and West Birmingham Hospitals, in the United Kingdom, said here at the EAU 24th Annual Congress.

In sexually active young men, acute epididymo-orchitis is most often caused by the sexually transmitted pathogens Chlamydia trachomatis or Neisseria gonorrhoeae. In Europe, rates of genital Chlamydial infection in young men and women have been soaring over the past 10 years, with prevalence rates up to 17% reported in asymptomatic populations, said Dr. Phillips.

"We suspected for a long time that, in the United Kingdom, patients who present to urologists with epididymitis probably don't get optimal service," he told Medscape Urology. "We know they are probably better managed by the genitourinary medical service, but because of the nature of the acute testicular pain that sometimes masquerades as torsion, they end up coming to the urologist."

But because urologists are not as good as genitourinary medical specialists at picking up sexually transmitted infections — "it doesn't appear at the top of our thought process" — the men get suboptimal management, he said.

To test their suspicions, the Birmingham investigators audited the management practices at 4 regionally separate British teaching hospitals: Sandwell and West Birmingham; Alexandra Hospital, in Redditch; University Hospital of North Staffordshire, in Stoke On Trent; and Royal Hallamshire Hospital, in Sheffield.

The records of 129 men younger than 35 years (age range, 16 to 34 years) who presented with acute scrotal pathology or urinary tract infections and who had a final diagnosis of epididymitis between January 2005 and December 2007 were selected for review.

The researchers found that compliance with recommended EAU guidelines was extremely poor in all 4 centers. Rates of diagnosis for sexually transmitted infection were very low (6%), and this was compounded by widespread use of suboptimal antibiotic regimes in 49% of cases, and variable follow-up, Dr. Phillips said.

"While urologists were unsurprisingly poor at sexual-contact tracing, referral to [genitourinary medical] clinics for further evaluation and follow-up was also poor — only 23% of patients were referred," he noted. The average attendance rate was a mere 14%.

Asked if he had a message for clinicians, Dr. Phillips said: "Ideally, if a patient presents to you and you think it's not torsion, it's probably best to refer that patient directly to the genitourinary medicine service. They are much better equipped to deal with these patients. But if this is not feasible — some centers don't have a [genitourinary medical] service on site or available around the clock — learn to think in terms of sexually transmitted infections in younger patients, and treat accordingly."

Florian Wagenlehner, MD, consultant in urology at the University of Giessen, in Germany, agreed that urologists are doing a dismal job of managing these patients. "The recommendations are not being implemented in clinical medicine, so this is something we all should work on. We write these guidelines and recommendations, but this is only the first step. Implementation of the guidelines into clinical medicine is the second step, and this is sincerely something we need to improve, especially with education. This is a useful study."

Dr. Phillips and Dr. Wagenlehner have disclosed no relevant financial relationships.

European Association of Urology (EAU) 24th Annual Congress: Abstract 430. Presented March 19, 2009.

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