What is the appropriate evaluation and management for a patient presenting with epididymitis?

Epididymitis Evaluation and Management

Initial Diagnostic Evaluation

All men presenting with suspected epididymitis require urethral testing for gonorrhea and chlamydia, urinalysis with Gram stain, and immediate consideration of testicular torsion as a surgical emergency. 1, 2

Essential Diagnostic Tests

• Urethral assessment: Obtain a Gram-stained smear of urethral exudate or intraurethral swab showing ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 3, 2

• STI testing: Perform nucleic acid amplification testing (NAAT) or culture of urethral specimen for N. gonorrhoeae and C. trachomatis 3, 2

• Urine evaluation: Examine first-void uncentrifuged urine for leukocytes if urethral Gram stain is negative; obtain culture and Gram stain for Gram-negative bacteria 3, 2

• Additional screening: Obtain syphilis serology and offer HIV counseling and testing 3, 2

Critical Differential: Testicular Torsion

Emergency surgical consultation is mandatory when pain onset is sudden and severe, or when initial testing does not confirm urethritis or urinary tract infection, because testicular viability is compromised within 4-6 hours. 3, 1, 4

• Torsion occurs more frequently in adolescents and patients without evidence of inflammation or infection 3
• Ultrasound with Doppler is the initial imaging modality to exclude torsion, abscess, or tumor 4

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days is the definitive treatment for sexually active men under 35 years. 3, 1, 2, 5

This regimen targets C. trachomatis and N. gonorrhoeae, the most common pathogens in this age group 3, 6, 7

Alternative regimen for men who practice insertive anal intercourse: 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 to cover enteric organisms 1, 6

Men Over 35 Years (Enteric Organism Etiology)

Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days is the recommended treatment for men over 35 years. 3, 1, 2, 4

• This age group typically has epididymitis caused by enteric Gram-negative organisms (primarily E. coli) secondary to bladder outlet obstruction 3, 6, 7
• Fluoroquinolones provide optimal coverage against these pathogens 1, 4

Adjunctive Management

Bed rest with scrotal elevation using a rolled towel or supportive underwear plus analgesics for pain control until fever and local inflammation subside. 3, 1, 2, 4

Mandatory Follow-Up and Red Flags

3-Day Reassessment

Patients must return within 3 days if pain, swelling, or fever do not improve, as this requires reevaluation of both diagnosis and treatment. 3, 1, 2, 4

Failure to improve warrants consideration of hospitalization and alternative diagnoses 3

Post-Treatment Evaluation

Persistent swelling and tenderness after completing the full antibiotic course requires comprehensive evaluation for testicular cancer, tuberculous epididymitis, fungal epididymitis, abscess, or infarction. 3, 1, 2, 4

Sexual Partner Management

All sexual partners from the 60 days preceding symptom onset must be evaluated and treated for gonorrhea and chlamydia, even if asymptomatic. 3, 2

• Patients must abstain from all sexual intercourse until both patient and partner(s) complete treatment and are symptom-free 3, 2
• This prevents reinfection and transmission to others 3, 2

Special Populations

HIV-Infected Patients

HIV-positive patients with uncomplicated epididymitis receive identical treatment as HIV-negative patients. 3, 1, 2, 4

However, fungal and mycobacterial causes are more common in immunosuppressed individuals, requiring earlier specialist involvement if standard therapy fails 3, 1, 2, 4

Common Pitfalls to Avoid

• Do not stop antibiotics early: The full 10-day course is mandatory even if symptoms improve, as premature discontinuation leads to treatment failure and complications including infertility and chronic pain 1, 6

• Do not miss torsion: Always rule out testicular torsion emergently in cases with sudden severe pain, especially in adolescents, as delayed diagnosis causes permanent testicular loss 3, 1, 2, 4

• Do not assume age-based etiology: Recent evidence shows STIs are not restricted to men under 35 years—14% of cases across all ages had STI pathogens, including 25 cases of C. trachomatis 7

• Do not neglect partner treatment: Failure to treat sexual partners leads to reinfection and continued transmission 3, 2