What is the diagnosis and treatment for epididymitis (inflammation of the epididymis)?

From the Guidelines

Epididymitis should be treated with antibiotics, such as ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis, and supportive care including rest, scrotal elevation, and pain relievers like ibuprofen. The diagnosis of epididymitis typically involves unilateral testicular pain and tenderness, hydrocele, and palpable swelling of the epididymis, as noted in studies 1. It is essential to consider testicular torsion, a surgical emergency, in all cases, especially when the onset of pain is sudden, severe, or when test results do not support a diagnosis of urethritis or urinary tract infection 1. The evaluation of men for epididymitis should include procedures such as midstream urine for culture, urethral swab/smear, and scrotal ultrasound examination, as outlined in the European Association of Urology guidelines 1. Empiric therapy is indicated before culture results are available, and treatment of epididymitis caused by C. trachomatis or N. gonorrhoeae will result in microbiologic cure of infection, improvement of signs and symptoms, prevention of transmission to others, and a decrease in potential complications 1.

Some key points to consider in the management of epididymitis include:

• The use of antibiotics active against Chlamydia trachomatis and Enterobacterales, such as ceftriaxone and doxycycline
• The importance of supportive care, including rest, scrotal elevation, and pain relievers like ibuprofen
• The need for urgent surgical exploration if testicular torsion is suspected
• The use of scrotal ultrasound examination to aid in diagnosis
• The consideration of parenteral therapy if severe infection is present, as noted in the 2024 European Association of Urology guidelines 1.

Overall, the goal of treatment is to achieve a microbiologic cure of infection, improve signs and symptoms, prevent transmission to others, and decrease potential complications, while also providing supportive care to manage symptoms and improve quality of life.

From the FDA Drug Label

Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days The recommended dose of doxycycline for epididymitis caused by N. gonorrhoeae or C. trachomatis is 100 mg by mouth, twice a day for at least 10 days 2.

• The dosage is the same for both N. gonorrhoeae and C. trachomatis infections.
• The treatment should be continued for at least 10 days.

From the Research

Definition and Causes of Epididymitis

• Epididymitis is the inflammation of the epididymis, commonly seen in the outpatient setting 3.
• The etiology of epididymitis is largely unknown, but reflux of urine into the ejaculatory ducts is considered a common cause in children under 14 years old 3.
• In sexually active males between 14 and 35 years old, Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens 3, 4.
• In men over 35 years old, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 3.

Symptoms and Diagnosis

• Epididymitis presents as the gradual onset of posterior scrotal pain, which may be accompanied by urinary symptoms such as dysuria and urinary frequency 3.
• Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position 3.
• Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, help guide therapy 4.

Treatment

• The treatment of epididymitis depends on the patient's age and the likely causative organisms 3.
• For sexually active males between 14 and 35 years old, a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice 3.
• For men over 35 years old, levofloxacin or ofloxacin alone is sufficient to treat the infection 3.
• Ofloxacin has been shown to be effective in treating epididymitis due to Escherichia coli in a rat model 5.
• In some cases, surgical intervention may be necessary due to abscess formation 6.