Management of Testicular Pain with Epididymal Thickening and Hydrocele
For a 38-year-old male patient with testicular pain, right epididymal thickening, and bilateral hydrocele, the next step should be empiric antibiotic treatment with ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days, along with non-narcotic analgesics for pain management.
Diagnostic Assessment
The ultrasound findings show:
- Right epididymal thickening in the distal portion
- Bilateral hydrocele (right greater than left)
- Left testicular simple cyst (3mm)
- Normal testicular blood flow bilaterally
These findings are consistent with epididymitis, which requires prompt treatment to prevent complications such as:
- Abscess formation
- Testicular infarction
- Chronic pain
- Infertility
Treatment Algorithm
1. Antimicrobial Therapy
Since the patient is 38 years old (>35 years), the most likely causative organisms are enteric bacteria, but sexually transmitted infections should still be considered:
First-line treatment 1:
- Ofloxacin 300 mg orally twice daily for 10 days OR
- Levofloxacin 500 mg orally once daily for 10 days
Alternative regimen (if sexual transmission is suspected):
- Ceftriaxone 250 mg IM in a single dose PLUS
- Doxycycline 100 mg orally twice daily for 10 days
2. Pain Management
Non-narcotic analgesics should be used for pain control:
- NSAIDs (ibuprofen or naproxen)
- Acetaminophen
Avoid narcotics for this condition, as they are not indicated as first-line therapy for epididymitis and carry risk of dependence, particularly in a prison setting
3. Adjunctive Measures
- Bed rest until fever and local inflammation subside
- Scrotal elevation
- Cold compresses for comfort
4. Follow-up
- Patient should be re-evaluated within 3 days of starting treatment 1
- If no improvement occurs within 3 days, reevaluation of both diagnosis and therapy is necessary
- Consider urological consultation if symptoms persist
Management of Hydrocele
The bilateral hydrocele may resolve with treatment of the underlying epididymitis. If the hydrocele persists after resolution of the infection:
- Consider aspiration and sclerotherapy as a non-surgical option for persistent symptomatic hydrocele 2
- Surgical correction (hydrocelectomy) may be considered if sclerotherapy fails
Important Considerations
Differential Diagnosis
If symptoms do not improve with appropriate antibiotics, consider alternative diagnoses:
- Testicular torsion (surgical emergency, but less likely given normal blood flow on ultrasound)
- Testicular tumor or malignancy 3, 4
- Testicular abscess
- Tuberculous epididymitis
Testing
Consider the following tests if not already performed:
- Urethral swab or first-void urine for STI testing (N. gonorrhoeae and C. trachomatis)
- Urinalysis and urine culture
- Complete blood count
- If symptoms persist, consider additional imaging or urological consultation
Pitfalls to Avoid
Do not prescribe narcotics as first-line pain management for epididymitis, especially in a prison setting where medication diversion is a concern
Do not delay treatment while waiting for culture results, as empiric therapy is indicated to prevent complications 1
Do not miss follow-up - failure to improve within 3 days requires reevaluation of both diagnosis and therapy
Do not overlook alternative diagnoses if the patient fails to respond to appropriate antibiotic therapy, particularly malignancy which can present with similar symptoms 3, 4
Do not ignore the hydrocele - while it may resolve with treatment of epididymitis, persistent hydrocele may require specific intervention 2