What is the appropriate diagnosis and treatment for a 30-year-old male presenting with a weak urinary stream, numb sensation, and pain in the groin and right testicle, with symptoms persisting since July?

Diagnosis and Treatment of Epididymitis in a 30-Year-Old Male

The most appropriate treatment for this 30-year-old male with symptoms suggestive of epididymitis is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days, not Bactrim DS. 1

Diagnostic Assessment

• The patient's presentation with weak urinary stream, numb sensation, groin and right thigh pain, and penile numbness since July is consistent with epididymitis, which is most commonly caused by sexually transmitted pathogens in men under 35 years of age 1
• In sexually active men under 35 years, the most common causative organisms are Chlamydia trachomatis and Neisseria gonorrhoeae 1
• Diagnostic evaluation should include:
  • Gram-stained smear of urethral exudate for diagnosis of urethritis and presumptive diagnosis of gonococcal infection 1
  • Culture 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
  • Syphilis serology and HIV counseling and testing 1

Differential Diagnosis

• Testicular torsion must be ruled out as it is a surgical emergency, though it occurs more frequently in adolescents and in patients without evidence of inflammation 1, 2
• Emergency evaluation for torsion is indicated when pain onset is sudden, pain is severe, or test results don't support urethritis/UTI diagnosis 1, 2
• Other conditions to consider include tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1

Treatment Recommendations

• For epididymitis most likely caused by gonococcal or chlamydial infection in men under 35 years:

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

• For epididymitis likely caused by enteric organisms (more common in men >35 years) or in patients allergic to cephalosporins/tetracyclines:

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

• Trimethoprim-sulfamethoxazole (Bactrim DS) is not recommended in the guidelines for epididymitis treatment 1

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1
• Patients should be instructed to refer sex partners for evaluation and treatment if contact was within 60 days preceding symptom onset 1

Follow-Up

• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Persistent swelling and tenderness after completing antibiotics should be comprehensively evaluated 1
• The differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 1

Important Considerations

• Hospitalization should be considered when severe pain suggests other diagnoses (torsion, testicular infarction, abscess) or when patients are febrile or might be noncompliant with treatment 1
• The European Association of Urology's 2024 guidelines also support the use of ceftriaxone plus doxycycline as first-line therapy for sexually transmitted epididymitis in younger men 1
• Bactrim DS (trimethoprim-sulfamethoxazole) is not recommended in any of the guidelines for epididymitis treatment in this age group 1