Treatment of Scrotal Edema from Epididymitis/Orchitis After Torsion is Ruled Out
Once ultrasound has excluded testicular torsion, treat epididymitis/orchitis with appropriate antibiotics targeting the most likely pathogens based on age and risk factors, combined with supportive measures including bed rest, scrotal elevation, and analgesics. 1, 2
Antibiotic Selection Based on Patient Age and Risk Profile
Young Men (14-35 years old)
- Initiate dual therapy with ceftriaxone plus doxycycline to cover Chlamydia trachomatis and Neisseria gonorrhoeae, which are the most common pathogens in this age group 2, 3
- Doxycycline dosing: 100 mg orally twice daily for at least 10 days 4, 2
- Ceftriaxone is given as a single dose to cover gonococcal infection 2
Older Men and Prepubertal Boys
- Use fluoroquinolones (ofloxacin or levofloxacin) as first-line therapy when coliform bacteria (E. coli, Pseudomonas, gram-positive cocci) are the suspected pathogens 5, 2
- This applies to men over 35 years and those without evidence of sexually transmitted pathogens 5
Essential Supportive Care Measures
- Bed rest until inflammation subsides 1
- Scrotal elevation to reduce edema and improve venous drainage 1, 3
- Analgesics for pain control 1
- Administer doxycycline with adequate fluids and food/milk if gastric irritation occurs 4
Critical Clinical Pitfalls to Avoid
Misdiagnosis Risk
- Always reassess patients who return with worsening scrotal pain despite epididymitis treatment, as testicular torsion can be initially misdiagnosed as epididymitis 6
- Up to 20% of epididymitis cases have concomitant orchitis, which may explain persistent symptoms 7
- Rare complications include global testicular infarction with a "string-of-beads" appearance on Doppler ultrasound 7
Diagnostic Confirmation
- Obtain urethral Gram stain, urinalysis and culture, and PCR assay for C. trachomatis and N. gonorrhoeae to guide therapy 2
- The gradual onset of pain and presence of lower urinary tract symptoms help differentiate epididymitis from torsion 2, 3
When to Reconsider the Diagnosis
- If symptoms worsen or fail to improve within 48-72 hours of appropriate antibiotic therapy, repeat ultrasound evaluation to exclude missed torsion, segmental infarction, or abscess formation 6, 8
- Persistent symptoms may indicate rare differential diagnoses including tumors, segmental testicular infarction, or testicular vasculitis 8
- Surgical consultation is warranted if there is clinical deterioration despite appropriate medical management 8