From the Guidelines
Epididymitis should be treated with empiric therapy, including antibiotics, before culture results are available, to achieve microbiologic cure, improve signs and symptoms, prevent transmission, and decrease potential complications. The treatment approach depends on the suspected cause, with sexually transmitted infections typically requiring a combination of antibiotics such as ceftriaxone and doxycycline 1. For non-sexually transmitted cases, often caused by urinary tract bacteria, fluoroquinolones like levofloxacin may be effective 1.
Key Considerations
- Patients with epididymitis suspected to be caused by N. gonorrhoeae or C. trachomatis should be instructed to refer sex partners for evaluation and treatment, with partners being referred if their contact was within 60 days preceding onset of symptoms 1.
- Epididymitis can be caused by various factors, including sexual activity, urinary tract abnormalities, and recent urinary tract procedures, with the most common causes varying by age and sexual practices 1.
- Treatment should also include supportive measures such as bed rest, scrotal elevation, and analgesics until fever and local inflammation have subsided 1.
Treatment Approach
- For suspected sexually transmitted infections, a combination of ceftriaxone 500mg as a single intramuscular dose plus doxycycline 100mg twice daily for 10 days is recommended.
- For non-sexually transmitted cases, fluoroquinolones like levofloxacin 500mg daily for 10 days may be effective.
- Patients should rest, elevate the scrotum with supportive underwear, apply ice packs to reduce swelling, and take over-the-counter pain relievers like ibuprofen or acetaminophen.
- Sexual abstinence is necessary until treatment is complete, and sexual partners should be treated if the cause is sexually transmitted 1.
From the FDA Drug Label
Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days
The recommended treatment for epididymitis caused by N. gonorrhoeae or C. trachomatis is doxycycline 100 mg orally twice a day for at least 10 days 2.
From the Research
Definition and Presentation of Epididymitis
- Epididymitis is characterized by inflammation of the epididymis, commonly presenting with gradual onset of posterior scrotal pain, potentially accompanied by urinary symptoms such as dysuria and urinary frequency 3.
- Physical findings typically include a swollen and tender epididymis with the testis in an anatomically normal position 3, 4, 5.
Etiology of Epididymitis
- The etiology of epididymitis varies by age group, with Neisseria gonorrhoeae and Chlamydia trachomatis being the most common pathogens in sexually active males aged 14 to 35 years 3, 4, 5.
- In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 3.
- In children younger than 14 years, reflux of urine into the ejaculatory ducts is considered the most common cause of epididymitis 3.
Treatment of Epididymitis
- Treatment of epididymitis is based on the likely causative organisms and patient age, with a single intramuscular dose of ceftriaxone and 10 days of oral doxycycline being the treatment of choice for sexually active males aged 14 to 35 years 3, 5.
- For men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen 3.
- In men older than 35 years, levofloxacin or ofloxacin alone is sufficient to treat epididymitis caused by enteric bacteria 3.
Importance of Accurate Diagnosis and Treatment
- Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making recognition and therapy vital to reduce patient morbidity 3.
- Accurate diagnosis and treatment are crucial, with the use of advanced microbiology techniques and studies of current practice providing new insights that challenge traditional management paradigms 6.
- Adherence to clinical practice guidelines remains short of available guidance, which may be improved by thorough clinical and microbiologic assessment, supported by a knowledge of the commonly associated pathogenic organisms 6, 7.