What is the recommended examination and treatment for a patient with suspected epididymitis?

Examination and Treatment for Suspected Epididymitis

For suspected epididymitis, perform a Gram-stained urethral smear looking for ≥5 polymorphonuclear leukocytes per oil immersion field, obtain nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis, and examine first-void urine for leukocytes; then initiate empiric therapy immediately with ceftriaxone 250 mg IM plus doxycycline 100 mg twice daily for 10 days in sexually active men under 35, or a fluoroquinolone alone for men over 35 or those with enteric risk factors. 1, 2, 3

Diagnostic Examination

Essential Laboratory Testing

• Urethral Gram stain: Examine urethral exudate or intraurethral swab for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis and provide presumptive diagnosis of gonococcal infection 1, 2

• Pathogen detection: Obtain culture or nucleic acid amplification test (NAAT) from intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1, 2

• Urine analysis: If urethral Gram stain is negative, examine first-void uncentrifuged urine for leukocytes and obtain culture with Gram-stained smear 1, 2

• Additional screening: Perform syphilis serology and offer HIV counseling and testing 1, 2

Clinical Examination Findings

• Men typically present with gradual onset of unilateral posterior scrotal pain and tenderness with epididymal swelling 2, 4

• The testis should be in anatomically normal position (distinguishing from testicular torsion) 2, 4

• Urinary symptoms such as dysuria and frequency may accompany the pain 4

Treatment Approach

Age-Based Empiric Therapy

For sexually active men under 35 years (targeting C. trachomatis and N. gonorrhoeae):

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 3, 5

• This regimen addresses the most common pathogens in this age group, where STIs account for the majority of cases 4, 6

For men over 35 years or those with enteric organism risk factors (bladder outlet obstruction, recent urinary instrumentation):

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2, 3

• E. coli and other enteric bacteria predominate in this population due to reflux of urine into ejaculatory ducts 3, 4, 6

For men who practice insertive anal intercourse (regardless of age):

• Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg twice daily for 10 days) 2, 3, 4

• This covers both STI pathogens and enteric organisms 4

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1, 2, 3

• These supportive measures reduce pain and swelling while antibiotics address the underlying infection 3

Critical Pitfalls and Follow-Up

Testicular Torsion Must Be Excluded

• Testicular torsion is a surgical emergency requiring immediate specialist consultation as testicular viability may be compromised 2, 3

• Emergency evaluation is indicated when pain onset is sudden and severe 2

• This is the most critical differential diagnosis that cannot be missed 3

Reassessment Timeline

• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1, 2, 3

• Persistent swelling and tenderness after completing antimicrobial therapy warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculous or fungal epididymitis 1, 2, 3

• Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making prompt recognition and therapy vital 4

Hospitalization Considerations

• Consider admission for patients with severe pain suggesting alternative diagnoses, fever, or likely non-compliance with treatment 3

Management of Sexual Partners

• Partners of patients with STI-related epididymitis should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1, 2, 3

• Patients must avoid sexual intercourse until both they and their partners complete treatment and are symptom-free 1, 2, 3

• Female partners of men with C. trachomatis epididymitis frequently have infection or pelvic inflammatory disease and require treatment 7

Special Populations

HIV-Infected Patients

• HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients 1, 2, 3

• However, fungi and mycobacteria are more likely causes in immunosuppressed patients 1, 2, 3

Contemporary Evidence on Etiology

• Recent molecular diagnostics demonstrate bacterial pathogens in 88% of antibiotic-naive patients, with E. coli accounting for 56% of cases 6

• STIs are present in 14% of cases and are not restricted to patients under 35 years 6

• C. trachomatis accounts for two-thirds of previously "idiopathic" epididymitis in young men and is often associated with oligospermia 7