Symptoms and Treatment of Epididymitis
Epididymitis should be treated with ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days for sexually transmitted infections in young adults, while older men should receive fluoroquinolones like levofloxacin 500 mg daily for 10 days to target enteric organisms. 1
Clinical Presentation
Key Symptoms
- Gradual onset of unilateral or bilateral scrotal pain
- Scrotal swelling
- Lower urinary tract symptoms:
- Dysuria
- Urinary frequency
- Urgency
- Fever (may be present)
- Pain relief when testicle is elevated over symphysis pubis (Prehn sign) 1, 2
Physical Examination Findings
- Swollen, tender epididymis and/or testis
- Testis in normal anatomic position
- Intact ipsilateral cremasteric reflex
- Possible reactive hydrocele as inflammation progresses 1
Diagnostic Approach
Imaging
- Ultrasound with Doppler is the imaging modality of choice
- Findings include:
- Increased blood flow to affected epididymis and testis (hyperemia)
- Enlarged, heterogeneous epididymis
- Possible testicular enlargement
- Possible reactive hydrocele 1
Differentiating from Testicular Torsion
Epididymitis must be distinguished from testicular torsion, which is a surgical emergency:
| Feature | Epididymo-Orchitis | Testicular Torsion |
|---|---|---|
| Onset | Gradual | Sudden |
| Pain relief with elevation | Yes (Prehn sign) | No |
| Cremasteric reflex | Present | Absent |
| Testicular position | Normal | High-riding |
| Doppler ultrasound | Increased blood flow | Decreased/absent blood flow |
Treatment Based on Age and Risk Factors
Young Adults (14-35 years)
- First-line treatment: Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 3
- Target organisms: N. gonorrhoeae and C. trachomatis
Men Who Practice Insertive Anal Intercourse
- Treatment: Ceftriaxone 250 mg IM in a single dose PLUS Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 1, 2
- Target organisms: Both STIs and enteric bacteria
Men Over 35 Years
- Treatment: Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 1, 2
- Target organisms: Enteric bacteria from urinary tract infections, often associated with bladder outlet obstruction
Children Under 14 Years
- Etiology is largely unknown but often attributed to reflux of urine into ejaculatory ducts 2
- Treatment should be guided by pediatric guidelines
Supportive Measures
- Bed rest
- Scrotal elevation
- Analgesics
- Adequate fluid intake 1
Follow-up and Complications
Follow-up Recommendations
- Microbiologic re-examination 7-10 days after completing therapy
- Consider rescreening for C. trachomatis and N. gonorrhoeae 4-6 weeks after completing therapy 1
- Evaluation and treatment of sex partners is crucial to prevent reinfection 1
Potential Complications
- Abscess formation
- Testicular ischemia (rare but possible)
- Global testicular infarction (rare but serious complication requiring surgical management) 4
- Infertility
- Chronic scrotal pain
- Testicular atrophy (rates ranging from 9.1% to 47.5%) 1
Special Considerations
Hospitalization Criteria
- Severe pain
- Febrile patients
- Patients who might be noncompliant with treatment 1
Chronic Epididymitis
- Defined as symptoms persisting >3 months
- May require specialized management approaches 1, 5
- The Chronic Epididymitis Symptom Index can be used for baseline evaluation and follow-up 5
Clinical Pitfalls to Avoid
Misdiagnosis of testicular torsion: Testicular torsion requires surgical intervention within 6-8 hours to prevent permanent gonadal loss. If in doubt, urgent urological consultation is warranted 1
Inadequate treatment duration: Ensure full 10-day course of antibiotics is completed to prevent chronic infection 1, 3
Failure to treat sexual partners: For sexually transmitted cases, partners must be treated to prevent reinfection 1
Missing underlying causes: In older men, investigate for bladder outlet obstruction or other urinary tract abnormalities 1, 2
Overlooking rare complications: Be vigilant for signs of testicular infarction, which may require surgical management 4