What is the treatment and drug of choice for epididymitis (inflammation of the epididymis) and spermatic cord inflammation in a 45-year-old male patient?

Treatment and Drug of Choice for Epididymitis in a 45-Year-Old Male

For a 45-year-old male with epididymitis and spermatic cord inflammation, the treatment of choice is oral levofloxacin 500 mg once daily or ofloxacin 300 mg twice daily for 10 days. 1

Etiology and Diagnosis

In men over 35 years of age, epididymitis is typically caused by:

• Enteric bacteria (most common)
• Associated with bladder outlet obstruction
• Reflux of urine into ejaculatory ducts 1, 2

Diagnostic workup should include:

• Urinalysis and urine culture
• Scrotal ultrasound with Doppler to rule out testicular torsion
• Consider STI testing if risk factors are present 1

Key diagnostic features of epididymitis vs. testicular torsion:

• Gradual onset of pain (vs. sudden in torsion)
• Positive Prehn sign (pain relief with elevation)
• Present cremasteric reflex
• Normal testicular position
• Increased blood flow on Doppler ultrasound 1

Treatment Regimen

First-line treatment for men >35 years:

• Levofloxacin 500 mg orally once daily for 10 days OR
• Ofloxacin 300 mg orally twice daily for 10 days 1, 2

Alternative regimens (if fluoroquinolones contraindicated):

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 3
• Azithromycin 1 g orally in a single dose (if compliance is a concern) 1

Supportive measures:

• Bed rest
• Scrotal elevation
• NSAIDs for pain management 1

Important Considerations

Fluoroquinolone risks:

• QTc prolongation
• Tendon rupture (especially in elderly)
• Neuropsychiatric disturbances
• Hypoglycemia 1

Monitoring and follow-up:

• Clinical improvement should occur within 3 days
• If no improvement, reevaluate diagnosis and therapy
• Consider surgical intervention if abscess formation occurs 1

Warning signs requiring immediate surgical exploration:

• Sudden onset of severe unilateral scrotal pain
• Nausea/vomiting
• High-riding testicle
• Absent cremasteric reflex 1

Special Considerations

Rising antibiotic resistance:

• Increasing fluoroquinolone resistance in enteric organisms is a growing concern 4
• Consider local resistance patterns when selecting antibiotics

Potential complications if untreated:

• Abscess formation
• Testicular ischemia
• Infertility
• Chronic scrotal pain 1, 2

Surgical management:

• Epididymotomy may be considered in cases of severe inflammation with impending vascular compromise 5
• Surgical intervention is indicated when medical therapy fails or abscess forms

In rare cases, non-infectious causes like vasculitis should be considered if there is no response to appropriate antibiotic therapy 6.