From the Guidelines
Epididymitis should be treated with antibiotics, with the specific treatment depending on the cause, and patients should be advised to rest, elevate the scrotum, and take pain relievers to manage symptoms. The condition is an inflammation of the epididymis, the coiled tube at the back of the testicle that stores and carries sperm. According to the Centers for Disease Control and Prevention guidelines 1, treatment depends on the cause but typically involves antibiotics for bacterial infections. For suspected sexually transmitted infections, a combination of ceftriaxone 500mg as a single intramuscular dose plus doxycycline 100mg twice daily for 10 days is recommended.
Causes and Risk Factors
The causes of epididymitis include:
- Sexually transmitted infections, such as Chlamydia trachomatis or Neisseria gonorrhoeae, which are common in sexually active men under 35 years old 1
- Non-sexually transmitted infections, often caused by urinary tract bacteria, such as Escherichia coli, which are more common in men over 35 years old or those with urinary tract abnormalities 1 Risk factors for epididymitis include sexual activity with multiple partners, urinary tract abnormalities, and recent urinary tract procedures.
Treatment and Management
While taking antibiotics, patients should:
- Rest to reduce discomfort and promote healing
- Elevate the scrotum when possible to reduce swelling
- Apply cold packs to reduce swelling and relieve pain
- Take over-the-counter pain relievers like ibuprofen (400-600mg every 6-8 hours) or acetaminophen (650mg every 6 hours) to manage pain and discomfort Sexual abstinence is advised until treatment is complete, and sexual partners should be treated if the cause is sexually transmitted 1. Most cases resolve within 1-3 weeks with proper treatment, though chronic epididymitis may require longer therapy.
Prevention and Complications
The condition occurs when bacteria travel from the urethra or bladder to the epididymis, causing inflammation, pain, and swelling. If left untreated, epididymitis can lead to complications such as infertility or chronic pain. Empiric therapy is indicated before culture results are available, and treatment of epididymitis caused by C. trachomatis or N. gonorrhoeae will result in microbiologic cure of infection, improvement of signs and symptoms, prevention of transmission to others, and a decrease in potential complications 1.
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 dosage of doxycycline for epididymitis caused by N. gonorrhoeae or C. trachomatis is 100 mg, twice a day, for at least 10 days 2.
- Key points:
- The dosage is the same for both N. gonorrhoeae and C. trachomatis infections
- Treatment should be continued for at least 10 days
- The dosage may be adjusted based on the severity of the infection and the patient's response to treatment.
From the Research
Definition and Causes of Epididymitis
- Epididymitis is the inflammation of the epididymis, commonly seen in the outpatient setting 3.
- The etiology of epididymitis is largely unknown, but reflux of urine into the ejaculatory ducts is considered the most common cause in children younger than 14 years 3.
- In sexually active males aged 14 to 35 years, Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens 3, 4.
- In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 3.
Symptoms and Diagnosis
- Epididymitis presents as the gradual onset of posterior scrotal pain, which may be accompanied by urinary symptoms such as dysuria and urinary frequency 3.
- Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position 3.
- Acute testicular torsion is the most important differential diagnosis of acute testicular pain, especially in younger men 4.
Treatment and Management
- The treatment of epididymitis is based on patient age and the likely causative organisms 3.
- A single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice for sexually active males aged 14 to 35 years 3.
- In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen 3.
- Levofloxacin or ofloxacin alone is sufficient to treat epididymitis in men older than 35 years 3.
- Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm 5.