What is the diagnosis and treatment for epididymitis (inflammation of the epididymis)?

From the Guidelines

Epididymitis should be treated with empiric antibiotics before culture results are available, with the goal of achieving microbiologic cure, improving signs and symptoms, preventing transmission to others, and decreasing potential complications, as recommended by the most recent guidelines 1. The treatment of epididymitis depends on the cause, but typically includes antibiotics for bacterial infections.

• For acute bacterial epididymitis, the European Association of Urology guidelines suggest that the predominant pathogens isolated are Enterobacterales, C. trachomatis, and Neisseria gonorrhoeae 1.
• The diagnostic and treatment algorithm for men with acute epididymitis is outlined in the 2024 guidelines, which prioritize empiric therapy before culture results are available 1.
• Pain management is essential and includes rest, scrotal elevation, and analgesics, as recommended by the Centers for Disease Control and Prevention 1.
• Sexual abstinence is advised until treatment is complete, and sexual partners should be evaluated if a sexually transmitted infection is confirmed.
• Symptoms typically improve within 3 days of starting antibiotics, but complete resolution may take weeks.
• If symptoms worsen or don't improve within 3 days, medical reevaluation is necessary to rule out complications or alternative diagnoses like testicular torsion, which requires emergency intervention.

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 dose of doxycycline for epididymitis is 100 mg, by mouth, twice a day for at least 10 days 2.

• The dosage is the same for epididymitis caused by N. gonorrhoeae or C. trachomatis.
• The treatment should be continued for at least 10 days.

From the Research

Causes of Epididymitis

• 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 14 to 35 years of age, Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens 3
• In men who practice insertive anal intercourse, an enteric organism is also likely 3
• 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 of Epididymitis

• Epididymitis presents as the gradual onset of posterior scrotal pain that 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

Treatment of Epididymitis

• A single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice for sexually active males 14 to 35 years of age 3
• Ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen for men who practice insertive anal intercourse 3
• Levofloxacin or ofloxacin alone is sufficient to treat epididymitis in men older than 35 years 3
• Quinolones, such as ciprofloxacin, are commonly prescribed as first-line antibiotics, but may not be the optimal choice for treating urogenital chlamydial infection 4
• Ciprofloxacin 500 mg orally twice daily is more effective than pivampicillin 700 mg orally twice daily in treating acute epididymitis in men above the age of 40 years 5

Antibiotic Use in Pediatric Patients

• A literature review of retrospective studies found that only 16.9% of pediatric patients with acute epididymitis had a positive urinalysis, and 14.9% had a positive urine culture 6
• Despite this, 85% of pediatric patients with acute epididymitis received antibiotics, suggesting that antibiotics may be overprescribed in this population 6
• Practitioners should consider only prescribing antibiotics to patients with acute epididymitis if there is an abnormal urinalysis or urine culture 6