From the Guidelines
Epididymitis should be diagnosed and treated promptly to prevent complications and improve patient outcomes, with empiric therapy indicated before culture results are available, as recommended by the Centers for Disease Control and Prevention 1. The diagnosis of epididymitis is typically made through a combination of physical examination, urinalysis, and sometimes imaging studies, with patients presenting with unilateral scrotal pain, swelling, and tenderness, often accompanied by fever and urethral discharge.
- Key diagnostic considerations include:
- Unilateral testicular pain and tenderness
- Hydrocele and palpable swelling of the epididymis
- Fever and urethral discharge
- Emergency testing for torsion may be indicated when the onset of pain is sudden, pain is severe, or the test results available during the initial examination do not enable a diagnosis of urethritis or urinary tract infection to be made, as noted in the 1998 guidelines for treatment of sexually transmitted diseases 1. Treatment depends on the likely cause, with different approaches for sexually transmitted infections versus non-sexually transmitted cases.
- For sexually transmitted epididymitis (common in men under 35), a combination of ceftriaxone 500 mg intramuscularly as a single dose plus doxycycline 100 mg orally twice daily for 10 days is recommended.
- For non-sexually transmitted cases (more common in older men), levofloxacin 500 mg orally once daily for 10 days or ciprofloxacin 500 mg orally twice daily for 10 days is typically prescribed. Supportive measures include:
- Bed rest
- Scrotal elevation
- Analgesics like ibuprofen 400-600 mg every 6-8 hours
- Ice packs to reduce inflammation and pain As an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided, as noted in the 2002 sexually transmitted diseases treatment guidelines 1. It is essential to evaluate and treat sexual partners if a sexually transmitted infection is confirmed, and patients should abstain from sexual activity until treatment is complete and symptoms resolve. Most cases resolve within 3 weeks with appropriate antibiotics, though chronic epididymitis may develop in some patients. The condition results from bacterial infection ascending from the urethra or bladder to the epididymis, with different pathogens responsible depending on age and sexual activity patterns.
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 diagnosis of epididymitis is not directly addressed in the drug label, but the treatment of acute epididymo-orchitis caused by N. gonorrhoeae or C. trachomatis with doxycycline is recommended as 100 mg, by mouth, twice a day for at least 10 days 2.
- The treatment duration is at least 10 days.
- The dosage is 100 mg, twice a day.
- The drug label does not provide information on the diagnosis of epididymitis.
From the Research
Diagnosis 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, 4.
- Examination of a patient with acute epididymo-orchitis classically reveals a swollen, tender testis with swelling of the epididymis which starts at the lower pole and moves up towards the head of the epididymis at the upper pole of the testes 5.
- Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, help guide therapy 4.
Treatment of Epididymitis
- The treatment of epididymitis is based on patient age and the likely causative organisms 3.
- In sexually active males 14 to 35 years of age, a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice 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.
- 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; levofloxacin or ofloxacin alone is sufficient to treat these infections 3.
- Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm 6.
Causes of Epididymitis
- Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens in sexually active males 14 to 35 years of age 3, 5, 4.
- Enteric bacteria are the most common cause of acute epididymitis in men older than 35 years 3, 5.
- Reflux of urine into the ejaculatory ducts is considered the most common cause of epididymitis in children younger than 14 years 3.