Acute Epididymitis: Workup and Management
Immediate Priority: Exclude Testicular Torsion
Testicular torsion must be ruled out first in any patient presenting with acute testicular pain, as it is a surgical emergency requiring intervention within 6–8 hours to preserve testicular viability 1, 2.
- Torsion is more common in adolescents and presents with sudden onset of severe pain, whereas epididymitis typically has gradual onset over hours to days 1, 2.
- A negative Prehn sign (no pain relief with scrotal elevation) suggests torsion, while a positive Prehn sign (pain relief with elevation) supports epididymitis 2, 3.
- If the diagnosis is uncertain or pain onset is abrupt and severe, obtain emergency Doppler ultrasound and immediate surgical consultation 1, 2.
Clinical Presentation
Epididymitis presents with:
- Unilateral testicular pain and tenderness localized to the epididymis, typically beginning at the lower pole and progressing upward 1, 2, 3.
- Palpable epididymal swelling with the testis in anatomically normal position 1, 3.
- Scrotal erythema and warmth as inflammation progresses 3.
- Reactive hydrocele may develop 1, 3.
- Fever in more severe cases 1, 3.
Diagnostic Workup
For Men <35 Years (Sexually Active)
The primary pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, so urethral testing—not just urinalysis—is essential 1, 2, 3.
- Obtain urethral Gram stain (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1, 2.
- Perform nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 1, 2, 3.
- If urethral Gram stain is negative, examine first-void urine for leukocytes 1, 2.
- Obtain syphilis serology and offer HIV testing 1, 2.
Common pitfall: Relying solely on urinalysis misses the majority of STI-related epididymitis in younger men, as these infections originate from urethral pathogens rather than urinary tract bacteria 3.
For Men ≥35 Years
Enteric Gram-negative organisms (especially E. coli) predominate, often associated with bladder outlet obstruction or urinary tract abnormalities 1, 2, 3.
- Obtain urinalysis (first-void uncentrifuged urine for leukocytes/pyuria) 1, 2, 3.
- Perform urine culture and Gram stain for Gram-negative bacteria 1, 2, 3.
- Consider syphilis serology and HIV testing 1, 2.
Age-Based Antibiotic Therapy
Men <35 Years
Treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover N. gonorrhoeae and C. trachomatis 1, 2, 3, 4.
- This regimen is recommended by the CDC and European Association of Urology as first-line therapy for sexually transmitted epididymitis 1, 2, 3.
- 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) to cover enteric organisms 2, 4.
Allergy alternative: If allergic to cephalosporins or tetracyclines, use levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice daily for 10 days 2.
Critical caveat: Ciprofloxacin is not optimal for chlamydial infection and should not be used as first-line therapy in men <35 years 2.
Men ≥35 Years
Treat with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2, 3, 4.
- Fluoroquinolone monotherapy is sufficient because sexually transmitted infections are less common in this age group 2.
- These agents provide adequate coverage for enteric Gram-negative organisms 1, 2, 3.
Do not use: Nitrofurantoin and fosfomycin are not recommended due to inadequate tissue penetration 3.
Adjunctive Supportive Measures
- Bed rest, scrotal elevation, and scrotal support until fever and local inflammation subside 1, 2, 3.
- Analgesics (NSAIDs or acetaminophen) for pain management 1, 3.
Follow-Up and Treatment Failure
Clinical improvement should be evident within 3 days of starting appropriate antibiotic therapy 1, 2, 3.
- If no improvement occurs within 3 days, reassess both the diagnosis and therapy 1, 2, 3.
- Consider alternative diagnoses: testicular torsion, tumor, abscess, testicular infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2, 3.
- If symptoms persist after completing antibiotics, perform comprehensive evaluation including Doppler ultrasound 1, 2, 3.
Management of Sexual Partners
For STI-related epididymitis, refer all sexual partners from the preceding 60 days for evaluation and treatment 1, 2.
- Patients should abstain from sexual intercourse until both the patient and all partners have completed therapy and are symptom-free 1, 2.
Hospitalization Criteria
Consider admission for:
- Severe pain suggesting torsion, abscess, or infarction 1.
- Fever indicating systemic involvement 1.
- Suspected noncompliance with outpatient antimicrobial regimen 1.
- Systemic illness (high fever, rigors, nausea, vomiting) suggesting abscess or Fournier's gangrene 3.