What is the most appropriate next step for a patient presenting with urethral discharge, scrotal pain, and swelling, and a history of recent unprotected sex, with physical examination findings of an enlarged and tender epididymis?

Acute Epididymitis: Immediate Antibiotic Treatment is Indicated

This patient requires immediate empiric antibiotic therapy without delay—urologic referral is not the appropriate next step for uncomplicated acute epididymitis. The clinical presentation of urethral discharge, recent unprotected sexual exposure, and tender epididymis in a young sexually active male strongly indicates sexually transmitted epididymitis, which is a medical condition managed with antibiotics, not a surgical emergency requiring urology consultation 1.

Clinical Diagnosis and Differentiation

The key clinical features that confirm this is epididymitis rather than testicular torsion include:

• Gradual onset over 3 days (torsion presents with sudden, severe pain) 2, 3
• Presence of urethral discharge indicating concurrent urethritis, which accompanies sexually transmitted epididymitis 1
• Recent unprotected sexual exposure pointing to STI etiology 1
• Tender epididymis on examination with testis in normal anatomic position 1

Testicular torsion must be excluded as it is a surgical emergency requiring intervention within 6-8 hours, but this patient's 3-day gradual onset makes torsion highly unlikely 2. The pending ultrasound will confirm increased blood flow to the epididymis (characteristic of epididymitis) rather than decreased flow (seen in torsion) 2, 3.

Immediate Empiric Antibiotic Therapy

Begin treatment immediately before culture results are available, as delays can lead to complications including infertility and chronic pain 1.

Recommended Regimen for Sexually Transmitted Epididymitis

Ceftriaxone 250 mg IM as a single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1. This combination targets both Neisseria gonorrhoeae and Chlamydia trachomatis, the predominant pathogens in sexually active men under 35 years 1, 4, 5, 6.

• The ceftriaxone provides immediate coverage for gonorrhea 1, 7
• The 10-day doxycycline course treats chlamydia, which causes two-thirds of "idiopathic" epididymitis cases in young men 8
• C. trachomatis was isolated from epididymal aspirates in a high proportion of cases and is often associated with oligozoospermia if untreated 8

Alternative Regimen

Ofloxacin 300 mg orally twice daily for 10 days can be used as an alternative, but only if the patient is allergic to cephalosporins or tetracyclines 1. However, fluoroquinone resistance in gonorrhea makes this less preferred for first-line therapy 1.

Adjunctive Supportive Measures

In addition to antibiotics, recommend 1:

• Bed rest until fever and local inflammation subside
• Scrotal elevation and support to reduce pain and swelling
• Analgesics (NSAIDs) for pain control 1, 3

Critical Diagnostic Workup

While initiating empiric therapy, obtain 1:

• Gram stain of urethral discharge (>5 PMNs per oil immersion field confirms urethritis) 1
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine 1
• Urinalysis and urine culture to evaluate for enteric organisms 1, 3
• Syphilis serology and HIV testing (all patients with STI-related epididymitis should be screened) 1

When to Consider Urology Referral

Urology consultation is NOT indicated for uncomplicated acute epididymitis but should be considered if 1:

• Failure to improve within 3 days of appropriate antibiotic therapy (requires re-evaluation of diagnosis and consideration of hospitalization) 1
• Severe pain suggesting alternative diagnoses such as testicular torsion, abscess, or testicular infarction 1
• Persistent swelling after completing antibiotics (evaluate for testicular cancer, tuberculous, or fungal epididymitis) 1
• Recurrent episodes requiring urologic evaluation for anatomic abnormalities 1

Partner Management and Follow-Up

Sexual partners must be evaluated and treated 1:

• Refer partners whose last sexual contact was within 30 days of symptom onset 1
• Female partners of men with C. trachomatis epididymitis are at high risk for cervical infection and PID 1, 8
• In one study, 6 of 9 female partners had antibody to C. trachomatis, with 2 having positive cervical cultures 8
• Instruct patient to abstain from sexual intercourse until both patient and partners complete therapy and are symptom-free 1

Common Pitfalls to Avoid

• Do not delay antibiotics waiting for ultrasound results in a patient with clear clinical epididymitis 1
• Do not refer to urology as first-line management for uncomplicated cases—this is a medical condition 1
• Do not use single-agent therapy in young sexually active men—dual coverage for gonorrhea and chlamydia is essential 1
• Do not assume age <35 years guarantees STI etiology—recent research shows STIs occur across all age groups, though more common in younger men 4, 5
• Do not forget to treat partners—untreated partners lead to reinfection and ongoing transmission 1, 8