What's the next step for a 50-year-old patient with persistent epididymitis (inflammation of the epididymis) symptoms and new onset of diffuse abdominal pain, bloating, and mild tenderness, with a negative kidney, ureter, and bladder (KUB) imaging and leukocytosis (elevated white blood cell count) after 7 days of doxycycline (vibramycin) treatment?

Management of Epididymitis with New Abdominal Symptoms

The patient should be admitted for evaluation of possible intra-abdominal complications given the elevated WBC count of 16,000 and new diffuse abdominal symptoms despite 7 days of doxycycline therapy for epididymitis.

Clinical Assessment

The presentation raises several concerns:

• Persistent epididymitis symptoms (only 50% improved) after 7 days of doxycycline
• New onset diffuse abdominal pain with bloating and mild tenderness
• Significantly elevated WBC count (16,000)
• Negative KUB (kidney, ureter, bladder) imaging

Differential Diagnosis

1. Treatment failure of epididymitis

   • Inadequate antibiotic coverage (resistant organisms)
   • Mycoplasma genitalium infection (responds better to azithromycin than doxycycline) 1
   • Tetracycline-resistant Ureaplasma urealyticum 1

2. Intra-abdominal complications

   • Possible spread of infection beyond the epididymis
   • Secondary infection or inflammatory process
   • Potential for abscess formation

Management Algorithm

Step 1: Admit for Further Evaluation

• The combination of persistent symptoms, new abdominal symptoms, and leukocytosis warrants inpatient evaluation 2
• This allows for close monitoring, IV antibiotics if needed, and expedited diagnostic workup

Step 2: Diagnostic Workup

• Urethral swab or first-void urine for culture and PCR testing for:
  • N. gonorrhoeae and C. trachomatis
  • T. vaginalis culture
  • M. genitalium if available 3
• Blood cultures
• Abdominal/pelvic CT scan to evaluate for complications
• Scrotal ultrasound to assess for abscess or other complications

Step 3: Antibiotic Management

• Switch to a fluoroquinolone-based regimen:
  • Levofloxacin 500 mg once daily or ofloxacin 300 mg twice daily 1, 4
  • Consider adding metronidazole 2g as a single dose for possible T. vaginalis 1

Rationale for Admission

1. Failed outpatient therapy: The patient has completed 7 days of doxycycline with only partial improvement 2

2. Systemic signs of infection: WBC count of 16,000 indicates significant inflammatory response 2, 5

3. New abdominal symptoms: The development of diffuse abdominal pain with bloating suggests possible spread of infection or a secondary process 5

Treatment Considerations

• For persistent epididymitis after doxycycline treatment, guidelines recommend:

  • Testing for tetracycline-resistant organisms 1
  • Switching to a fluoroquinolone (levofloxacin or ofloxacin) for enteric organisms 2, 4
  • Adding metronidazole if T. vaginalis is suspected 1

• In men over 35 years (this patient is 50), enteric bacteria are more commonly the causative organisms, which respond better to fluoroquinolones 2, 4

Common Pitfalls to Avoid

1. Continuing the same antibiotic: Continuing doxycycline when symptoms are persistent and new symptoms have developed is inappropriate

2. Outpatient management: Given the elevated WBC count and new abdominal symptoms, outpatient management risks missing serious complications

3. Delayed imaging: Abdominal/pelvic imaging should not be delayed as complications may require surgical intervention

4. Ignoring partner treatment: Once stabilized, ensure partners are evaluated and treated to prevent reinfection 1

Follow-up Recommendations

• After clinical improvement and discharge:
  • Complete the full course of antibiotics
  • Follow-up within 1-2 weeks to ensure resolution of symptoms
  • Abstain from sexual activity until patient and partners are treated and symptoms resolve 1
  • Consider retesting in 3 months if sexually transmitted pathogen was identified 6