What is the diagnosis and treatment for a patient with testicular pain, postvoid dribbling, fever, and pelvic pain?

Diagnosis and Treatment of Testicular Pain with Fever and Urinary Symptoms

The clinical presentation of testicular pain, postvoid dribbling, fever, and pelvic pain is most consistent with acute epididymitis, which requires immediate empiric antibiotic therapy based on patient age and risk factors. 1

Diagnostic Approach

Key Clinical Features Distinguishing Epididymitis from Surgical Emergencies

• Unilateral testicular pain and tenderness with palpable epididymal swelling and hydrocele are hallmark findings of epididymitis. 1
• Fever, pyuria, dysuria, and urethral discharge strongly support epididymitis rather than testicular torsion. 2
• Gradual onset of pain (typically >12 hours) with elevated temperature above 37.5°C favors epididymitis over torsion. 3
• Sudden, severe pain onset requires emergency evaluation for testicular torsion, which is a surgical emergency that can compromise testicular viability. 1

Essential Diagnostic Testing

• Obtain a Gram-stained urethral smear or intraurethral swab to identify urethritis (>5 polymorphonuclear leukocytes per oil immersion field) and presumptively diagnose gonococcal infection. 1
• Perform nucleic acid amplification testing on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis. 1
• Examine first-void uncentrifuged urine for leukocytes if urethral Gram stain is negative, with culture and Gram stain of this specimen. 1
• Order syphilis serology and offer HIV counseling and testing, as sexually transmitted epididymitis indicates risk for other infections. 1, 4
• Routine urinalysis should be performed in all patients with acute scrotal pain, particularly when epididymo-orchitis is suspected, as UTI is present in 7.2% of cases. 5

Age-Based Etiology

• In men under 35 years, epididymitis is most commonly caused by sexually transmitted C. trachomatis or N. gonorrhoeae, usually accompanied by asymptomatic urethritis. 1, 4
• In men over 35 years, epididymitis typically results from Gram-negative enteric organisms associated with urinary tract infections. 1, 4
• Sexually transmitted enteric organisms (e.g., E. coli) can cause epididymitis in men who are the insertive partner during anal intercourse. 1

Treatment Algorithm

Empiric Antibiotic Therapy (Start Before Culture Results)

For patients under 35 years with suspected gonococcal or chlamydial infection:

• Ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1
• Updated 2021 CDC guidelines recommend ceftriaxone monotherapy for gonorrhea with weight-based dosing, though the combination with doxycycline remains standard for epididymitis to cover chlamydia. 6
• Doxycycline is now the preferred treatment for chlamydia over azithromycin. 6

For patients over 35 years or when enteric organisms are suspected:

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1, 4
• These fluoroquinolones provide optimal coverage against enteric Gram-negative organisms causing epididymitis in older men. 4
• Ciprofloxacin 500 mg orally twice daily for 10 days is an alternative fluoroquinolone option. 4

For patients allergic to cephalosporins and/or tetracyclines:

• Use fluoroquinolone regimens (levofloxacin or ofloxacin) as described above. 1

Adjunctive Supportive Care

• Prescribe bed rest with scrotal elevation (using rolled towel or supportive underwear) until fever and local inflammation subside. 1, 4
• Provide analgesics for pain control during the acute phase. 1, 4

Hospitalization Criteria

• Consider hospitalization when severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess), when patients are febrile, or when medication compliance is questionable. 1

Critical Follow-Up and Red Flags

Early Reassessment

• Reevaluate both diagnosis and therapy if no improvement occurs within 3 days of initiating treatment. 1, 4
• Immediate surgical consultation is required for sudden, severe pain that could indicate testicular torsion. 1, 4

Post-Treatment Evaluation

• Swelling and tenderness persisting after completing antimicrobial therapy requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis. 1, 4
• Palpable masses or persistent swelling after treatment completion necessitate immediate surgical consultation. 4

Sexual Partner Management and Prevention

• Instruct patients to refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment if N. gonorrhoeae or C. trachomatis is confirmed or suspected. 1, 4
• Partners should be treated even if asymptomatic. 4
• Patients must abstain from all sexual intercourse until both they and their partners complete therapy and are symptom-free. 1, 4

Common Pitfalls to Avoid

• Do not stop antibiotics when pain improves—the full 10-day course is essential to prevent chronic complications including infertility and chronic pain. 1, 4
• Do not miss testicular torsion in adolescents or men without evidence of inflammation/infection, as this occurs more frequently in these populations. 1
• Do not assume normal urinalysis excludes epididymitis, as urinalysis is often normal in testicular torsion but abnormal in epididymitis. 2
• GC testing has limited yield without symptoms suggestive of sexually transmitted infections and a normal ultrasound, but should still be performed in at-risk populations. 5

Special Populations

• HIV-infected patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients. 1, 4
• Immunosuppressed patients are more likely to have fungal or mycobacterial causes requiring different treatment approaches. 1, 4