Treatment of Acute Epididymitis with Scrotal Wall Edema
Immediate Antibiotic Therapy
For this patient with acute right-sided epididymitis, initiate ceftriaxone 250 mg intramuscularly as a single dose plus doxycycline 100 mg orally twice daily for 10 days. 1, 2
The age of the patient determines the antibiotic selection:
If the patient is under 35 years old: Use ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days, as this covers the most common sexually transmitted pathogens (Chlamydia trachomatis and Neisseria gonorrhoeae) in this age group 3, 1
If the patient is 35 years or older: Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days, which provides better coverage against enteric Gram-negative organisms that predominate in older men 1, 4
The ultrasound findings of enlarged, hypervascular right epididymis with increased scrotal wall thickness (0.4 cm vs 0.3 cm on left) confirm acute inflammatory changes requiring immediate empiric antibiotic therapy before culture results return 3
Supportive Care Measures
Prescribe bed rest with scrotal elevation and analgesics until fever and local inflammation subside. 3, 1, 4
- Scrotal elevation using supportive underwear or a rolled towel reduces venous congestion and edema 4
- The scrotal wall edema (0.4 cm thickness) and minimal peritesticular fluid (0.12 ml) documented on ultrasound should improve with these conservative measures 5
- NSAIDs can be used for both analgesia and anti-inflammatory effects 6
Research demonstrates that scrotal support devices combined with local cold compress significantly reduce scrotal swelling scores (1.01 vs 1.38, P < 0.05) and improve total effectiveness rates (83.33% vs 65%, P < 0.05) compared to antibiotics alone 5
Mandatory Follow-Up Timeline
Reevaluate the patient within 3 days if pain, swelling, or fever do not improve, as this requires reassessment of the diagnosis and possible treatment modification. 1, 4
Failure to improve within 72 hours raises concern for:
- Testicular abscess formation 3, 1
- Testicular torsion (surgical emergency) 3, 4
- Alternative diagnoses such as tumor or infarction 1, 4
Sexual Partner Management
All sexual partners within the past 60 days must be evaluated and treated if the infection is caused by gonorrhea or chlamydia, even if asymptomatic. 1, 4
- The patient should abstain from sexual intercourse until both he and his partner(s) complete treatment and are symptom-free 4
- Obtain urethral cultures or nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis to guide partner notification 3
Additional Diagnostic Testing
Perform HIV counseling and testing plus syphilis serology, as sexually transmitted epididymitis indicates risk for other infections. 3, 4
The diagnostic workup should include:
- Gram stain of urethral exudate or intraurethral swab (>5 PMNs per oil immersion field indicates urethritis) 3
- Urine culture and microscopic analysis if urethral Gram stain is negative 3
- The bilateral non-specific inguinal lymph nodes noted on ultrasound may represent reactive changes but warrant clinical correlation 7
Critical Pitfalls to Avoid
Do not discontinue antibiotics when symptoms improve—complete the full 10-day course to prevent treatment failure, chronic pain, and infertility. 1, 4
Consider hospitalization if severe pain suggests alternative diagnoses (torsion, abscess, infarction) or if the patient is febrile or unlikely to comply with oral antibiotics. 3, 1
The multiple punctate echogenic foci seen bilaterally in the testicular parenchyma likely represent microlithiasis, which is incidental but should be documented for future reference 8
The minimal peritesticular fluid (0.12 ml) and scrotal wall thickening are expected findings in acute epididymitis and should resolve with appropriate treatment 7, 8