What is the likely diagnosis and treatment for a male patient presenting with symptoms of epididymitis or orchitis?

Epididymitis and Orchitis: Diagnosis and Treatment

Diagnosis

In a male patient presenting with unilateral testicular pain and tenderness with palpable epididymal swelling, the diagnosis is epididymitis, and treatment must be age-stratified based on the most likely causative organisms. 1, 2

Clinical Presentation

• Patients typically present with gradual onset of unilateral testicular pain and tenderness 1, 2
• Palpable swelling of the epididymis is characteristic, often with hydrocele 1, 2
• Fever may be present in more severe cases 2
• Urethritis symptoms (dysuria, urinary frequency) commonly accompany sexually transmitted epididymitis 3, 4

Critical Differential: Rule Out Testicular Torsion

• Testicular torsion is a surgical emergency that must be excluded immediately, especially in adolescents and when pain onset is sudden and severe 1, 2
• Emergency specialist consultation is required if torsion is suspected, as testicular viability is compromised within 4-6 hours 1, 5
• Torsion is more likely when there is no evidence of inflammation/infection and the cremasteric reflex is absent 6

Diagnostic Workup

• Gram-stained smear of urethral exudate showing ≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis 3, 1, 2
• Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis 3, 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 3, 1, 2
• Urine culture and Gram stain to identify enteric organisms 3, 2
• Syphilis serology and HIV testing 3, 1, 2

Treatment

For Men <35 Years (Sexually Transmitted Etiology)

The recommended regimen is ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 3, 1, 2, 7

• C. trachomatis and N. gonorrhoeae are the most common pathogens in this age group 3, 4, 8
• Chlamydia (12.3%) is more common than gonorrhea (3.1%) among men <35 years with epididymitis 8
• Doxycycline 100 mg orally twice daily for at least 10 days is specifically indicated for acute epididymo-orchitis caused by C. trachomatis or N. gonorrhoeae 7

For Men Who Practice Insertive Anal Intercourse

Use ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1, 2

• Enteric organisms (E. coli) are common in this population due to sexually transmitted enteric pathogens 3
• Fluoroquinolones provide coverage for both enteric organisms and atypical pathogens 1, 2

For Men ≥35 Years (Enteric Organism Etiology)

Use levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 3, 1, 2

• Gram-negative enteric organisms (primarily E. coli) are the most common pathogens in this age group 3, 8, 9
• These infections are typically associated with urinary tract abnormalities such as bladder outlet obstruction or benign prostatic hyperplasia 3, 9, 5
• E. coli was the most common bacteria in urine cultures (N=20), followed by Streptococcus, Klebsiella, Pseudomonas, and Serratia 8

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 3, 1, 2
• Adequate fluid intake with oral medications to reduce esophageal irritation 7
• Doxycycline may be given with food or milk if gastric irritation occurs 7

Follow-Up and Complications

• Patients must show improvement within 3 days of starting treatment; failure to improve requires reevaluation of diagnosis and therapy 1, 2
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain 4

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

Special Considerations

• HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients 3, 2
• Fungi and mycobacteria are more likely in immunosuppressed patients 1, 2
• Hospitalization is indicated for severe pain suggesting torsion/abscess/infarction, fever, or anticipated noncompliance 3, 2

Common Pitfalls

• Only 50.1% of men diagnosed with epididymitis in emergency departments are tested for gonorrhea and chlamydia, leading to missed STI diagnoses 8
• Rising fluoroquinolone resistance in E. coli isolates may necessitate alternative antimicrobials in the future 9
• All patients with sexually transmitted urethritis should have serologic testing for syphilis, as high-dose short-course antibiotics may mask incubating syphilis 3, 10