What are the treatment recommendations for an 82-year-old man with acute epididymitis and small bilateral hydroceles?

From the Guidelines

For an 82-year-old man with acute epididymitis and small bilateral hydroceles, I recommend empiric antibiotic therapy with oral fluoroquinolones such as ciprofloxacin 500 mg twice daily or levofloxacin 500 mg once daily for 10-14 days, as outlined in the European Association of Urology guidelines on urological infections 1. This approach is based on the fact that in up to 90% of cases, the condition is caused by migration of pathogens from the urethra or bladder, which can be identified via appropriate diagnostics, and the predominant pathogens isolated are Enterobacterales, C. trachomatis, and Neisseria gonorrhoeae. Some key points to consider in the management of this patient include:

• Pain management with NSAIDs like ibuprofen 400-600 mg three times daily or naproxen 500 mg twice daily, unless contraindicated due to renal impairment or other comorbidities.
• Scrotal support and elevation, along with bed rest and application of cold packs for the first 24-48 hours, will help reduce pain and swelling.
• The small bilateral hydroceles likely don't require specific intervention unless they become symptomatic or enlarge.
• A urine culture should be obtained before starting antibiotics to guide therapy if the empiric treatment fails.
• If symptoms don't improve within 72 hours, reevaluation is necessary to rule out testicular torsion, abscess formation, or other complications, as suggested by previous guidelines 1. It's worth noting that in elderly men, epididymitis is commonly caused by urinary tract pathogens like E. coli rather than sexually transmitted infections, which is why broad-spectrum antibiotics targeting gram-negative organisms are preferred. The patient should be advised to complete the full course of antibiotics even if symptoms resolve earlier.

From the FDA Drug Label

Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days

The recommended treatment for an 82-year-old man with acute epididymitis is doxycycline 100 mg, by mouth, twice a day for at least 10 days 2.

• The presence of small bilateral hydroceles does not affect the treatment recommendation for acute epididymitis.
• Doxycycline is the recommended antibiotic for the treatment of acute epididymitis caused by N. gonorrhoeae or C. trachomatis.
• The patient's age does not require a dosage adjustment for doxycycline, as the pharmacokinetic parameters in older volunteers were similar to those in younger volunteers.

From the Research

Treatment Recommendations

• For an 82-year-old man with acute epididymitis, the treatment is based on the likely causative organisms, which in this age group are usually enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 3.
• The recommended treatment regimen for men older than 35 years with epididymitis is levofloxacin or ofloxacin alone 3.
• It is essential to note that the choice of the initial antibiotic regimen is empirical and based on the most likely causative pathogen 4.
• The treatment of acute epididymitis is crucial to reduce patient morbidity, as untreated cases can lead to infertility and chronic scrotal pain 3.

Considerations for Geriatric Patients

• The leading cause of scrotal pain in the geriatric population is epididymitis 5.
• Testicular torsion is rare in adult men, but diagnosis in the geriatric population is often delayed due to lack of awareness 5.
• The presence of small bilateral hydroceles may not affect the treatment of acute epididymitis, but it is essential to consider the overall clinical picture and potential complications 3, 4.

Limitations of Current Evidence

• There is a need for more prospective studies evaluating treatment regimens for acute epididymitis, as highlighted by a systematic review that found only one study meeting the criteria for inclusion 6.
• The current treatment guidelines are based on empirical evidence and knowledge of antimicrobial activities of specific agents, rather than direct trial data 4.