From the Guidelines
Acute epididymitis should be treated with empiric antibiotics, such as ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis, as soon as possible to prevent complications and improve outcomes. The treatment approach depends on the suspected cause, with sexually transmitted infections being more common in men under 35 and urinary tract infections more common in men over 35 1.
Key Considerations
- The European Association of Urology guidelines recommend a clinical assessment, midstream urine for culture, and urethral swab/smear to guide treatment decisions 1.
- For severe infections, parenteral therapy with ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis may be necessary 1.
- Pain management is essential and includes NSAIDs like ibuprofen 400-600mg every 6-8 hours, scrotal support, and rest.
- Some key points to consider in the treatment of acute epididymitis include:
- The importance of prompt treatment to prevent complications like abscess formation or chronic epididymitis.
- The need for patients to complete the full antibiotic course even if symptoms improve quickly.
- The recommendation for sexual abstinence until treatment is complete.
- The potential need for scrotal ultrasound examination or other diagnostic tests to guide treatment decisions.
Treatment Approach
The treatment approach for acute epididymitis should be guided by the suspected cause and severity of the infection.
- For men under 35 with suspected sexually transmitted infections, treatment with antibiotics such as doxycycline or azithromycin may be recommended.
- For men over 35 or with urinary tract infections, treatment with fluoroquinolones like levofloxacin may be preferred.
- In all cases, prompt treatment with empiric antibiotics is crucial to prevent complications and improve outcomes 1.
From the Research
Definition and Causes of Acute Epididymitis
- Acute epididymitis is a common infectious disease, with a bacterial origin in most cases 2, 3, 4.
- The most common pathogens in men between 14 and 35 years of age are Chlamydia trachomatis and Neisseria gonorrhoeae, while in other age groups, coliform bacteria are the primary pathogens 3.
- Escherichia coli is a common causative pathogen, identified in 56% of antibiotic-naive patients in one study 2.
Diagnosis and Treatment
- Diagnosis is typically based on symptoms, physical findings, and laboratory studies, including urethral Gram stain, urinalysis, and culture, as well as polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae 3.
- Initial outpatient therapy is empirical and targets the most common pathogens, with ceftriaxone and doxycycline recommended for C. trachomatis and N. gonorrhoeae, and ofloxacin or levofloxacin for coliform bacteria 3.
- Advanced microbiology techniques and studies of current practice provide new insights that have challenged traditional management paradigms 4.
- The use of antibiotics should be considered only if there is an abnormal urinalysis or urine culture, especially in pediatric patients 5.
Antibiotic Management
- Ofloxacin has been shown to be an effective antimicrobial agent for the treatment of epididymitis due to E. coli in a rat model 6.
- Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm 4.
- Adherence to clinical practice remains short of available guidance, which may be improved by thorough clinical and microbiologic assessment, supported by a knowledge of the commonly associated pathogenic organisms, and the appropriate choice of tests required for their identification 4.