What is the next appropriate step in managing a 65-year-old man with acute epididymitis, presenting with scrotal pain and swelling, increased urinary output, and trace hematuria, who has a history of benign prostatic hyperplasia (BPH) managed with tamsulosin (flomax), after restarting tamsulosin?

Management of Acute Epididymitis in a 65-Year-Old Man with BPH

The next appropriate step after restarting tamsulosin for this 65-year-old man with acute epididymitis is to initiate antibiotic therapy with levofloxacin or ofloxacin for 10 days. 1, 2

Clinical Assessment and Diagnosis

The patient presents with classic signs of acute epididymitis:

• Left-sided scrotal pain and swelling for 24 hours
• Erythematous and enlarged left scrotum
• Warm left epididymis on examination
• Tenderness to palpation of the suprapubic abdomen
• Trace blood in urine
• History of BPH with recent discontinuation of tamsulosin

This clinical picture strongly suggests acute epididymitis, which is the most common cause of acute scrotal pain in adult men, particularly those over 35 years of age 3.

Treatment Algorithm

1. Restart tamsulosin (0.4 mg daily) for BPH management

   • Tamsulosin helps relieve bladder outlet obstruction, which is likely contributing to the patient's condition 4, 5
   • Take 30 minutes after the same meal each day 4

2. Initiate antibiotic therapy immediately:

   • For men >35 years: Levofloxacin 500 mg once daily OR ofloxacin 300 mg twice daily for 10 days 1, 2
   • Rationale: In men over 35, epididymitis is typically caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 1

3. Pain management:

   • NSAIDs for pain and inflammation
   • Scrotal elevation and support
   • Ice packs to reduce swelling

4. Imaging:

   • Scrotal ultrasound with Doppler: To confirm diagnosis and rule out testicular torsion 3
   • Ultrasound is the imaging modality of choice with high sensitivity (96-100%) and specificity (84-95%) 3

Important Considerations

• Rule out testicular torsion: Although less common in men >35 years, testicular torsion requires immediate surgical intervention. The gradual onset (24 hours) and physical findings favor epididymitis over torsion 3.

• BPH connection: The patient's untreated BPH (ran out of tamsulosin 10 days ago) likely contributed to the development of epididymitis through urinary reflux into the ejaculatory ducts 1.

• Follow-up: Schedule follow-up in 3-7 days to assess treatment response. Symptoms should improve within 48-72 hours of starting antibiotics.

Potential Pitfalls

1. Delayed treatment: Untreated acute epididymitis can lead to infertility and chronic scrotal pain 1.

2. Misdiagnosis: Failing to rule out testicular torsion, which requires surgical intervention within 6-8 hours of symptom onset to prevent testicular loss 3.

3. Inadequate antibiotic coverage: For men >35 years with BPH, enteric organisms are the most likely pathogens, requiring appropriate antibiotic selection 1, 2.

4. Medication interactions: Monitor for dizziness or orthostatic hypotension when restarting tamsulosin, especially in combination with other medications 4.

By following this treatment approach, you address both the acute infectious process (epididymitis) and the underlying contributing factor (BPH with urinary obstruction), which should lead to resolution of symptoms and prevent recurrence.