What are the symptoms and treatment options for epididymitis?

Epididymitis Symptoms and Treatment

Epididymitis typically presents with unilateral testicular pain and tenderness, accompanied by palpable swelling of the epididymis and often a hydrocele, with treatment varying based on patient age and likely causative organisms. 1

Clinical Presentation

• Unilateral testicular pain and tenderness are the primary symptoms of epididymitis 1
• Palpable swelling of the epididymis is a characteristic physical finding 1
• Hydrocele (fluid collection around the testicle) is commonly present 1
• Fever may occur in more severe cases 1
• Urethritis often accompanies sexually transmitted epididymitis, though it may be asymptomatic 2
• Symptoms typically have a gradual onset, which helps differentiate from testicular torsion 3
• Lower urinary tract symptoms such as dysuria and urinary frequency may be present 3

Etiology by Age Group

• Children (<14 years): Often idiopathic, with reflux of urine into ejaculatory ducts considered the most common cause 3
• Young men (14-35 years): Most commonly caused by sexually transmitted infections:
  • Chlamydia trachomatis (most prevalent) 4
  • Neisseria gonorrhoeae 2
  • Enteric organisms in men who practice insertive anal intercourse 2
• Older men (>35 years): Usually caused by:
  • Gram-negative enteric organisms (especially E. coli) 4
  • Often associated with urinary tract infections, recent instrumentation, or anatomical abnormalities 2

Diagnostic Evaluation

• Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
• First-void urine examination for leukocytes if urethral Gram stain is negative 2
• Culture and Gram-stained smear of uncentrifuged urine 2
• Syphilis serology and HIV testing are recommended 1

Differential Diagnosis

• Testicular torsion: Surgical emergency more common in adolescents, presenting with sudden severe pain and often no signs of inflammation 1
• Testicular infarction 1
• Testicular abscess 1
• Testicular cancer 1
• Tuberculous or fungal epididymitis (especially in immunocompromised patients) 1

Treatment

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, 5

For men >35 years or enteric organisms suspected:

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

Adjunctive measures:

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

Follow-Up and Complications

• Improvement should be seen within 3 days of starting treatment 1
• Failure to improve requires reevaluation of both diagnosis and therapy 1
• Persistent swelling and tenderness after completing antibiotics warrants comprehensive evaluation 1
• Potential complications include:
  • Infertility 3
  • Chronic scrotal pain 3
  • Abscess formation 1
  • Testicular infarction 1

Management of Sex Partners

• For STI-related epididymitis, sex partners should be referred for evaluation and treatment 1
• Partners should be referred if contact occurred within 60 days preceding symptom onset 2
• Patients should avoid sexual intercourse until they and their partners are cured (therapy completed and no symptoms) 2

Hospitalization Criteria

• Severe pain suggesting other diagnoses (torsion, infarction, abscess) 2
• Febrile patients 2
• Patients who might be noncompliant with antimicrobial regimen 2

Special Considerations

• In children with acute epididymitis who have no urinary abnormalities, the condition may be self-limiting and antibiotics might not be indicated 6
• For HIV-infected patients with uncomplicated epididymitis, the same treatment regimen as HIV-negative patients is recommended 1
• Fungal and mycobacterial causes should be considered more strongly in immunocompromised patients 1