• Audit
• chlamydia
• epididymitis
• epididymo-orchitis
• genitourinary medicine
• urology

Despite overwhelming evidence of the growing public health problem caused by untreated Chlamydia trachomatis,1 it remains a problem largely ignored by the urological fraternity. It is the most commonly reported bacterial sexually transmitted infection (STI) in Europe, and the commonest cause of epididymo-orchitis in sexually active young men.2 Many of these cases present initially to the urologist with suspected testicular torsion, but remain under the urologist once the diagnosis of epididymo-orchitis is made. Clear and specific guidelines for the management of sexually active young men with epididymo-orchitis have been available for over the past decade,3 4 yet surveys suggest many urologists still disregard these recommendations.5 We audited the management of young men with acute epididymo-orchitis by the urology departments of five regionally separate UK teaching hospitals.

All urological admissions for acute scrotum or urinary tract infection in men younger than 35 years were audited at each centre for a period of at least 18 months, from which all sexually active men under 35 years of age with a final diagnosis of epididymitis were selected (n=204). The median age was 24 years (range 14–34). First void urine samples or urethral swabs were sent on only 15 cases (7%, interhospital range 2–11%), of which 11 tested positive for chlamydia. Mid-stream urine samples were sent in 103 cases (46%, interhospital range 42–56%), of which 11 (11%) confirmed the presence of enteric organisms on culture. Chlamydial studies were requested on mid-stream urine rather than first void urine samples for 11 patients, all of which tested negative for chlamydia. Overall, microbiological confirmation of the infective organism was achieved in only 21 (10%) cases, reflecting the inadequacy of appropriate testing. Ciprofloxacin was the single most commonly prescribed antibiotic (44%, interhospital range 14–72%), despite increasing evidence of chlamydial resistance to this agent, and 31% were prescribed less than the recommended 2 week course of antibiotics. Just over half (55%, interhospital range 41–64%) had a follow-up appointment made with the urology department, but 32% failed to attend. Less than one quarter (22%, interhospital range 12–38%) had instructions to attend the genitourinary medicine (GUM) clinic for follow-up and sexual contact tracing, although almost two-thirds of those that did successfully attended.

Despite an informal education policy through the urological and surgical directorates to the front-line staff, repeat of the audit cycle in two of the centres yielded only a marginal improvement with first void urine samples or urethral swabs still only being sent in 18% of cases, and only 44% being referred to the GUM services.

We feel this confirms that urologists remain poor at managing epididymo-orchitis in sexually active young men, and are therefore almost certainly failing to diagnose many cases of chlamydia and other sexually transmitted infections in exactly the group both most at risk and most likely to have multiple partners. GUM departments therefore need to take the initiative and devise management protocols with their local urologists for young men presenting with acute epididymo-orchitis, particularly as these may represent the first and only symptomatic presentation among this key population.