What is the appropriate diagnosis and treatment for a young to middle-aged man presenting with symptoms of epididymoorchitis?

Epididymoorchitis: Diagnosis and Treatment

Immediate Priority: Exclude Testicular Torsion

Before diagnosing epididymoorchitis, testicular torsion must be ruled out immediately, as it is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss. 1

• Testicular torsion is more common in adolescents and young men, with peak incidence in postpubertal boys 1
• Key features favoring torsion: abrupt onset of severe pain, absence of urinary symptoms, and negative urinalysis (though normal urinalysis does not exclude torsion) 1
• If clinical suspicion for torsion is high, proceed directly to surgical exploration without delay for imaging 2
• For intermediate suspicion, obtain urgent Duplex Doppler ultrasound showing decreased/absent testicular blood flow and the "whirlpool sign" of twisted spermatic cord 1

Age-Based Diagnostic Approach

Men <35 Years Old

Epididymoorchitis in this age group is most frequently caused by sexually transmitted pathogens Chlamydia trachomatis and Neisseria gonorrhoeae, and empiric treatment should target both organisms immediately. 3

Diagnostic workup:

• Nucleic acid amplification test (NAAT) on intraurethral swab or first-void urine for C. trachomatis and N. gonorrhoeae (most sensitive test) 3
• Gram stain of urethral exudate showing >5 polymorphonuclear leukocytes per oil immersion field indicates urethritis 3
• First-void urine examination for leukocytes if urethral Gram stain is negative 3
• Syphilis serology and HIV testing 3
• Culture of N. gonorrhoeae when antibiotic resistance is a concern 3

Men >35 Years Old

In this age group, gram-negative and gram-positive enteric organisms similar to those causing urinary tract infections are the primary pathogens. 3, 4

Diagnostic workup:

• Midstream urine culture for aerobic bacteria 3
• Consider underlying urological abnormalities: benign prostatic hyperplasia, urethral stricture, recent urinary instrumentation 3, 4
• Surgically obtained tissue may be cultured if invasive infection suspected 3

Empiric Antibiotic Treatment

For Men <35 Years (Sexually Transmitted Pathogens)

Recommended regimen:

• Ceftriaxone 250 mg IM as a single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 3, 2, 5

This combination targets both N. gonorrhoeae and C. trachomatis and should be initiated immediately before culture results return 2

For Men >35 Years or Enteric Organisms

Recommended regimen:

• Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 3

Critical caveat: Rising fluoroquinolone resistance in E. coli isolates means alternative antimicrobials may be necessary based on local resistance patterns 4

Alternative Regimens

• For patients allergic to cephalosporins and/or tetracyclines: fluoroquinolones as above 3
• For men who are insertive partners during anal intercourse: treat for enteric organisms 3

Adjunctive Supportive Care

All patients require:

• Bed rest until fever and local inflammation subside 3, 2
• Scrotal elevation 3, 2
• Analgesics for pain control 3, 2

Hospitalization Criteria

Consider hospitalization when: 3

• Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess)
• Patient is febrile
• Concern for medication non-compliance
• No clinical improvement within 48-72 hours of conservative treatment 6

Mandatory Follow-Up and Reassessment

Reassessment within 3 days is mandatory. 3, 2

Failure to improve within 72 hours requires:

• Reevaluation of both diagnosis and therapy 3, 2
• Consider complications: abscess formation, testicular infarction, testicular cancer, tuberculosis, or fungal epididymitis 3, 7, 8
• Repeat ultrasound to assess for abscess or testicular necrosis 7, 8

Warning signs of testicular ischemia/necrosis: 7, 8

• Worsening pain despite antibiotics
• Development of scrotal abscess
• Absence of testicular arterial vascularity on Doppler ultrasound
• Clinical presentation inconsistent with ultrasound findings (ultrasound has limitations) 7

Surgical Intervention

Indications for surgery: 6

• No clinical improvement within 48-72 hours of appropriate antibiotic therapy
• Presence of testicular or epididymal abscess
• Testicular malacia (softening)
• Loss of palpatory differentiation between epididymis and testis with hydrocele
• Suspected testicular infarction/necrosis 7, 8

Surgical options range from organ-sparing procedures to orchiectomy depending on extent of tissue destruction. 6

Management of Sexual Partners

For sexually transmitted epididymoorchitis: 3, 2

• All sexual partners within 60 days preceding symptom onset must be evaluated and treated
• Patient should abstain from sexual intercourse until both patient and partners complete therapy and are asymptomatic
• Repeat syphilis and HIV testing at 6 weeks, 3 months, and 6 months if initial results negative 2

Special Considerations

Mumps orchitis in adolescents/young adults: 2

• Ask specifically about parotid gland swelling in preceding 10 days
• Diagnosis by IgM serology for mumps antibodies or acute/convalescent IgG serology 3

Fungal and mycobacterial disease: 3

• Uncommon but require special media and communication with laboratory
• Consider in immunocompromised patients or those not responding to standard therapy
• Organisms include Blastomyces, Histoplasma, Coccidioides, and Mycobacterium tuberculosis 3