What are the symptoms and treatment options for epididymitis?

Symptoms and Treatment of Epididymitis

Epididymitis typically presents with unilateral testicular pain and tenderness, accompanied by palpable swelling of the epididymis and often a hydrocele. 1 The condition requires prompt diagnosis and treatment to prevent complications such as infertility and chronic pain.

Clinical Presentation

• Gradual onset of posterior scrotal pain (unlike the sudden onset in testicular torsion) 2
• Unilateral testicular pain and tenderness 1
• Palpable swelling of the epididymis 1
• Hydrocele may be present 1
• May be accompanied by urinary symptoms such as dysuria and frequency 2
• Fever may be present in more severe cases 1

Differential Diagnosis

• Testicular torsion (surgical emergency) - more common in adolescents and presents with sudden onset of severe pain 1
• Testicular infarction 1
• Testicular abscess 1
• Testicular cancer 1
• Tuberculous or fungal epididymitis (especially in immunocompromised patients) 1

Diagnostic Evaluation

The following procedures should be performed to evaluate epididymitis:

• Gram-stained smear of urethral exudate or intraurethral swab specimen to diagnose urethritis (≥5 polymorphonuclear leukocytes per oil immersion field) 1
• Culture of urethral exudate or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
• Examination of first-void urine for leukocytes if urethral Gram stain is negative 1
• Culture and Gram-stained smear of uncentrifuged urine 1
• Syphilis serology and HIV counseling and testing 1

Treatment

Treatment is based on the patient's age and likely causative organisms:

For men <35 years (likely STI-related):

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice a day for 10 days 1, 3

For men >35 years or those with suspected enteric organisms:

• Ofloxacin 300 mg orally twice a day for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days 1, 4

Adjunctive measures:

• Bed rest and scrotal elevation until fever and local inflammation subside 1
• Analgesics for pain management 1

Special Considerations

Men who practice insertive anal intercourse:

• Consider enteric organisms as potential pathogens 2
• Ceftriaxone with 10 days of oral levofloxacin or ofloxacin is recommended 2

HIV-infected patients:

• Same treatment regimen as HIV-negative patients for uncomplicated epididymitis 1
• Consider fungal and mycobacterial causes more strongly in immunocompromised patients 1

Follow-Up

• Improvement should be seen within 3 days of starting treatment 1
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Persistent swelling and tenderness after completing antimicrobial therapy should be evaluated comprehensively 1

Management of Sex Partners

• For cases caused by STIs (N. gonorrhoeae or C. trachomatis), sex partners should be referred for evaluation and treatment 1
• Partners should be referred if contact with the index patient was within 60 days preceding symptom onset 1
• Patients should avoid sexual intercourse until they and their partners are cured (therapy completed and no symptoms) 1

Complications

• Untreated acute epididymitis can lead to infertility 2
• Chronic scrotal pain may develop 2
• Abscess formation 1
• Testicular infarction 1

Hospitalization Criteria

Consider hospitalization when:

• Severe pain suggests other diagnoses (torsion, infarction, abscess) 1
• Patient is febrile 1
• Patient might be noncompliant with antimicrobial regimen 1