What is the treatment for epididymo-orchitis and how to clinically correlate it?

From the Guidelines

Epididymo-orchitis treatment should be initiated promptly with antibiotics targeting the likely causative organisms, prioritizing the patient's age and risk factors to guide the choice of antibiotic regimen. For suspected sexually transmitted infections in men under 35, prescribe ceftriaxone 500mg IM as a single dose plus doxycycline 100mg twice daily for 10-14 days, as recommended by the Centers for Disease Control and Prevention 1. For enteric or urinary pathogens more common in older men, use levofloxacin 500mg daily or ciprofloxacin 500mg twice daily for 10-14 days.

Key Considerations

• The treatment approach is based on the likely causative organisms, with Chlamydia and Neisseria gonorrhoeae more common in younger men and E. coli and other enteric organisms more common in older men or those with urinary tract abnormalities 1.
• Supportive measures are essential and include:
  • Bed rest
  • Scrotal elevation with a folded towel or athletic supporter
  • Nonsteroidal anti-inflammatory drugs like ibuprofen 400-600mg three times daily
  • Ice packs to reduce swelling and pain
• Clinical correlation involves assessing risk factors (sexual activity, urinary tract abnormalities), physical examination findings (unilateral scrotal swelling, tenderness, erythema, prehn's sign), and laboratory tests (urinalysis, urine culture, STI testing) 1.
• Ultrasound may be necessary to differentiate from testicular torsion, which requires immediate surgical intervention.
• Treatment response should be evident within 48-72 hours with decreased pain and swelling.
• Follow-up in 1-2 weeks is recommended to ensure resolution, and sexual partners should be treated if an STI is confirmed.

Rationale

The rationale for different antibiotic regimens is based on age-related differences in pathogens, with the goal of achieving microbiologic cure of infection, improving signs and symptoms, preventing transmission to others, and decreasing potential complications (e.g., infertility or chronic pain) 1. While older guidelines may suggest broader spectrum treatments 1, the most recent and specific recommendations for epididymo-orchitis should be followed, prioritizing the patient's age and risk factors to guide the choice of antibiotic regimen.

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 treatment for epididymo-orchitis caused by N. gonorrhoeae or C. trachomatis is doxycycline 100 mg orally, twice a day, for at least 10 days 2.

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

From the Research

Epididymo-orchitis Treatment

• The treatment of epididymo-orchitis depends on the patient's age and the likely causative organisms 3, 4, 5.
• In sexually active males 14 to 35 years of age, Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens, and a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice in this age group 4, 5.
• In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen 5.
• In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction; levofloxacin or ofloxacin alone is sufficient to treat these infections 3, 5.

Clinical Correlation

• Epididymo-orchitis typically presents with a gradual onset of scrotal pain and symptoms of lower urinary tract infection, including fever 6, 4.
• Physical findings include a swollen, tender epididymis or testis located in the normal anatomic position with an intact ipsilateral cremasteric reflex 6, 4.
• Laboratory studies, including urethral Gram stain, urinalysis and culture, and polymerase chain reaction assay for C. trachomatis and N. gonorrhoeae, help guide therapy 4.
• A classification system for acute epididymo-orchitis (AEO) has been developed, which divides AEO into three stages and recommends an approach to its treatment based on examination results and clinical outcomes 7.

Important Considerations

• Acute testicular torsion is the most important differential diagnosis of acute testicular pain, especially in younger men, and requires immediate referral to secondary care for surgery 6.
• Patients who are in severe pain or systemically unwell should be referred for analgesia, IV antibiotics, and hydration 6.
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making recognition and therapy vital to reduce patient morbidity 5.