From the Guidelines
Epididymitis is an inflammation of the epididymis, typically characterized by unilateral testicular pain and tenderness, hydrocele, and palpable swelling of the epididymis, as described in the 2002 guidelines for treatment of sexually transmitted diseases 1. The evaluation of men for epididymitis should include procedures to rule out testicular torsion, a surgical emergency, especially when the onset of pain is sudden, severe, or when test results do not support a diagnosis of urethritis or urinary-tract infection 1. Some key points to consider in the diagnosis and management of epididymitis include:
- The condition is often caused by sexually transmitted infections, such as Chlamydia trachomatis or Neisseria gonorrhoeae, particularly in sexually active men under 35 years old 1.
- Non-sexually transmitted epididymitis associated with urinary tract infections caused by Gram-negative enteric organisms occurs more frequently among men over 35 years, those who have recently undergone urinary tract instrumentation or surgery, and those with anatomical abnormalities of the urinary tract 1.
- Empiric therapy with antibiotics is indicated before culture results are available, aiming for microbiologic cure, improvement of signs and symptoms, prevention of transmission, and reduction of potential complications such as infertility or chronic pain 1.
- Supportive care, including bed rest, scrotal elevation, and analgesics, is recommended until fever and local inflammation have subsided 1. The recommended treatment for suspected bacterial epididymitis in adults is doxycycline 100 mg orally twice daily for 10 days, with the addition of ceftriaxone 500 mg intramuscularly as a single dose if chlamydia or gonorrhea is suspected, along with over-the-counter pain medications like ibuprofen 400-600 mg every 6-8 hours for pain relief 1.
From the Research
Definition and Causes of Epididymitis
- Epididymitis is defined as inflammation of the epididymis 2, 3, 4
- The cause is usually an infectious agent, with the main route of access to the epididymis being retrograde propagation through the vas deferens 2
- In young adults, the main causative agents are Chlamydia trachomatis and Neisseria gonorrhoeae 2, 3, 4
- In prepubertal children and adults older than 35 years, epididymitis is usually caused by enterobacteria 2, 3, 4
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, 4
- Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position 3, 4
- Acute testicular torsion is an important differential diagnosis of acute testicular pain, especially in younger men 4
Treatment and Management
- Treatment is based on patient age and the likely causative organisms 2, 3, 4
- In sexually active males aged 14-35 years, a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice 3
- In men older than 35 years, levofloxacin or ofloxacin alone is sufficient to treat epididymitis caused by enteric bacteria 3, 4
- Patients with severe disease should be admitted for parenteral therapy with an aminoglycoside and a cephalosporin in combination, followed by oral cotrimoxazole or a second-generation quinolone 2