From the Guidelines
For a 62-year-old male with right epididymitis not improving after intramuscular antibiotics, I recommend reevaluating the diagnosis and therapy, as failure to improve within 3 days of treatment initiation requires a comprehensive assessment 1. The patient's lack of improvement suggests that the initial treatment may not be effective, and a reevaluation of the diagnosis is necessary to rule out other conditions such as tumor, abscess, infarction, testicular cancer, TB, or fungal epididymitis 1.
Key Considerations
- The patient should be evaluated for urinary tract abnormalities or obstruction with urinalysis, urine culture, and possibly ultrasound imaging.
- Supportive measures including scrotal elevation, ice packs, and non-steroidal anti-inflammatory drugs like ibuprofen 600 mg three times daily should be continued.
- If symptoms persist despite appropriate antibiotic therapy, consider urologic consultation to rule out testicular torsion, abscess formation, or malignancy.
- Epididymitis in older men is typically caused by urinary tract pathogens rather than sexually transmitted infections, and inadequate response to initial therapy may indicate resistant organisms, anatomical abnormalities, or an incorrect diagnosis 1.
Treatment Options
- Switching to oral fluoroquinolones such as levofloxacin 500 mg daily or ciprofloxacin 500 mg twice daily for 14-21 days may be considered.
- If there's concern for drug-resistant organisms, consider adding doxycycline 100 mg twice daily.
Important Notes
- Complete resolution may take several weeks even with appropriate therapy.
- The patient's age and lack of improvement suggest that a thorough evaluation and possible consultation with a urologist are necessary to determine the best course of action.
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 next step for a 62-year-old male with right epididymitis that is not improving after intramuscular (IM) treatment is to consider oral doxycycline 100 mg, twice a day, for at least 10 days 2.
From the Research
Next Steps for Epididymitis Treatment
The patient, a 62-year-old male with right epididymitis, has not shown improvement after intramuscular (IM) treatment. Considering the age group and the lack of improvement, the following steps can be taken:
- Re-evaluation of the patient to determine the cause of epididymitis, as coliform bacteria are the primary pathogens in this age group 3
- Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, to guide therapy 3
- Consideration of alternative antibiotic treatments, such as ofloxacin or levofloxacin, if coliform bacteria are suspected 3
- Supportive measures, such as scrotal elevation and bed rest, to manage acute epididymitis 4
- Referral to a urology subspecialist for further evaluation and management, especially if the patient has underlying conditions or if the infection is severe 4
Considerations for Antibiotic Resistance
Given the rising concern of antibiotic resistance, particularly with Neisseria gonorrhoeae 5, it is essential to:
- Monitor the patient's response to treatment and adjust the antibiotic regimen as needed
- Consider the use of ceftriaxone, as recommended by the 2021 CDC STI Treatment Guidelines, for the treatment of uncomplicated gonorrhea 5
- Be aware of the potential risks of severe urogenital infections associated with certain medications, such as SGLT2 inhibitors, in patients with uncontrolled type 2 diabetes mellitus 6