Epididymitis Diagnosis and Treatment

Clinical Presentation

The Centers for Disease Control and Prevention recommends that epididymitis typically presents with unilateral testicular pain and tenderness, accompanied by palpable swelling of the epididymis and often a hydrocele 1, 2
Unilateral testicular pain and tenderness are common symptoms of epididymitis 2
Palpable swelling of the epididymis is a characteristic finding in epididymitis 1
Hydrocele may be present in patients with epididymitis 3
Fever may be present in more severe cases of epididymitis 1

Testicular torsion, a surgical emergency, is more common in adolescents and presents with sudden onset of severe pain, and is a key differential diagnosis for epididymitis 2
Testicular infarction is a potential differential diagnosis for epididymitis 1
Testicular abscess is a possible differential diagnosis for epididymitis 1
Testicular cancer is a differential diagnosis for epididymitis 2
Tuberculous or fungal epididymitis, especially in immunocompromised patients, is a differential diagnosis for epididymitis 3

A Gram-stained smear of urethral exudate or intraurethral swab specimen showing ≥5 polymorphonuclear leukocytes per oil immersion field is diagnostic for urethritis, a common cause of epididymitis 2
Culture of urethral exudate or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis is recommended for diagnosis of epididymitis 1
Examination of first-void urine for leukocytes is recommended if urethral Gram stain is negative 2
Culture and Gram-stained smear of uncentrifuged urine is recommended for diagnosis of epididymitis 1
Syphilis serology and HIV counseling and testing are recommended for patients with epididymitis 2

For men <35 years with epididymitis, the Centers for Disease Control and Prevention recommends ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days 1, 2
For men >35 years or those with suspected enteric organisms, ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days is recommended 2, 3
Bed rest and scrotal elevation until fever and local inflammation subside are recommended as adjunctive measures for epididymitis 2
Analgesics for pain management are recommended for patients with epididymitis 1

For HIV-infected patients with epididymitis, the same treatment regimen as HIV-negative patients is recommended for uncomplicated epididymitis 3
Fungal and mycobacterial causes should be considered more strongly in immunocompromised patients with epididymitis 3

Improvement should be seen within 3 days of starting treatment for epididymitis, and failure to improve requires reevaluation of both diagnosis and therapy 2
Persistent swelling and tenderness after completing antimicrobial therapy should be evaluated comprehensively 3

For cases of epididymitis caused by STIs, sex partners should be referred for evaluation and treatment 2
Partners should be referred if contact with the index patient was within 60 days preceding symptom onset 3
Patients should avoid sexual intercourse until they and their partners are cured (therapy completed and no symptoms) 3

Severe pain suggesting other diagnoses, such as torsion, infarction, or abscess, is a criterion for hospitalization 1
Patient febrility is a criterion for hospitalization 1
Patient noncompliance with antimicrobial regimen is a criterion for hospitalization 1