What is the next step in management for a patient diagnosed with epididimo-orchitis?

Management of Epididymo-Orchitis

The next step in management for a patient diagnosed with epididymo-orchitis is to administer Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice daily for 10 days to target both N. gonorrhoeae and C. trachomatis. 1

Treatment Approach Based on Patient Age and Risk Factors

First-line Antimicrobial Therapy

• For young adults (14-35 years) with likely sexually transmitted infection etiology:

  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 1, 2

• For men over 35 years (likely enteric organism etiology):

  • Alternative regimens include:
    • Ofloxacin 300 mg orally twice daily for 10 days OR
    • Levofloxacin 500 mg orally once daily for 10 days 1
  • Note: Rising fluoroquinolone resistance in enteric organisms necessitates careful antibiotic selection 3

Special Considerations

• For men who practice insertive anal intercourse: Consider coverage for both STIs and enteric organisms 1
• For suspected brucellosis: Consider combination therapy with doxycycline and rifampicin for 6 weeks 4
• For mumps orchitis: Supportive care is the mainstay of treatment 5
• For tuberculosis epididymo-orchitis: Consider in immunocompromised patients or those from high-prevalence countries 5

Supportive Measures

• Bed rest
• Scrotal elevation
• Adequate analgesics
• Adequate fluid intake 1

Indications for Hospitalization

• Severe pain
• Febrile patients
• Patients who might be noncompliant with treatment
• Suspected abscess formation 1

Follow-up and Monitoring

• Assess for symptom improvement within 48-72 hours
• If no improvement, consider:
  • Ultrasound to rule out abscess formation
  • Alternative diagnoses
  • Resistant organisms 1

Complications to Monitor

• Abscess formation
• Testicular ischemia (rare)
• Infertility
• Chronic scrotal pain 1

Important Clinical Pearls

1. Always differentiate from testicular torsion which is a surgical emergency requiring intervention within 6-8 hours:

   • Epididymo-orchitis: Gradual onset, positive Prehn sign (pain relief with elevation), normal testicular position
   • Testicular torsion: Sudden onset, negative Prehn sign, high-riding testis 1

2. TWIST Score can help assess risk of testicular torsion:

   • Points for: testicular swelling, hard testicle, absent cremasteric reflex, nausea/vomiting, high-riding testis
   • Score ≥5 points has 92.9% positive predictive value for torsion 1

3. Partner notification and treatment is essential for cases of sexually transmitted epididymo-orchitis to prevent reinfection 5

4. Antibiotic resistance considerations: The BASHH guideline notes high levels of quinolone-resistant gonorrhea, supporting the recommendation for ceftriaxone plus doxycycline in those at high risk for gonorrhea 5

5. Rare causes to consider in specific contexts:

   • Brucellosis in endemic areas 4, 6
   • Melioidosis in tropical zones 7
   • Tuberculosis in endemic areas or immunocompromised patients 5