Epididymitis

Epididymitis in men is most often caused by chlamydia (C. trachomatis) and neisseria (N. gonorrhoeae). Epididymitis that occurs as a result of sexual contact is often asymptomatic.

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Causes epididymitis

The most common cause of epididymitis in men younger than 35 years is C. trachomatis or N. gonorrhoeae. In addition, epididymitis caused by the sexually transmitted Escherichia coli is common in homosexual men who are the active partner in anal intercourse. Epididymitis resulting from sexual contact is usually accompanied by urethritis, which is often asymptomatic. Epididymitis that is not related to sexual transmission is usually associated with urinary tract infection caused by gram-negative enterobacteria and is most common in men older than 35 years and in men who have had recent instrumentation or surgery on the urinary tract or who have anatomical defects.

Although most patients can be treated on an outpatient basis, hospitalization is indicated when pain is severe, when other diseases such as torsion, testicular infarction, abscess cannot be excluded, or when the patient has a fever.

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Symptoms epididymitis

Symptoms of epididymitis include one-sided pain and tenderness in the testicle. If epididymitis is accompanied by displacement of the testicle, surgical intervention should always be considered, especially in adolescents. Immediate evaluation for displacement may be indicated if the pain attack is sudden in onset, the pain in the testicle is very severe, or if the results of tests that can be done at the initial visit do not allow a diagnosis of urethritis or urinary tract infection.

Diagnostics epididymitis

Epididymitis is diagnosed by performing the following procedures:

• Gram staining of a smear of urethral exudate or material from an intraurethral swab to diagnose urethritis (> 5 polymorphonuclear leukocytes per field of view with immersion microscopy) or to exclude gonococcal infection.
• Culture of urethral exudate or material from an intraurethral swab or DNA amplification tests (with material from an intraurethral swab or first portion of urine) for N. gonorrhoeae, and

C. trachomatis.

• Examination of the first portion of urine for leukocytes when the Gram-stained smear is negative. Culture and Gram-stained smear examination of uncentrifuged urine.
• Serological testing for syphilis, as well as counseling and testing for HIV infection.

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Treatment epididymitis

Empirical treatment of epididymitis is indicated pending culture results. Epididymitis caused by N. gonorrhoeae and C. trachomatis is treated with the aim of:

• microbiological cure,
• relief of symptoms and signs
• preventing the transmission of infection to other persons and
• reducing the risk of possible complications such as infertility or chronic pain syndrome.

Epididymitis: Treatment according to recommended regimens

Epidemiitis caused by gonococcal or chlamydial infection:

• Ceftriaxone 250 mg intramuscularly once
• plus Doxycycline 100 mg orally twice daily for 10 days.

Epidemiitis caused by intestinal microorganisms, or if the patient is allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally 2 times a day for 10 days.

As an addition to treatment until the temperature drops and local inflammation disappears, bed rest, a supportive bandage on the scrotum and the administration of analgesics are recommended.

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Follow-up care for patients with epididymitis

Failure to improve within 3 days requires reconsideration of both the epididymitis diagnosis and treatment, and possible hospitalization. If swelling and tenderness persist after completion of antimicrobial therapy, the possibility of testicular cancer, tuberculous, or fungal epididymitis should be considered.

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Management of sexual partners

Patients with epididymitis caused by N. gonorrhoeae should be instructed to have their sexual partners examined and treated. Sexual partners of such patients should be examined and treated if exposure occurs within 60 days of the onset of symptoms in the patient.

Patients who have epididymitis should also be instructed to abstain from sexual intercourse until the patient and partner(s) are cured. In the absence of microbiological confirmation of cure, this means until treatment is completed and the patient and partner(s) are symptom-free.

Special considerations for epididymitis

HIV infection

Uncomplicated epididymitis in HIV-infected individuals requires the same treatment as in individuals without HIV infection. However, in patients with weakened immune systems, cases of the disease caused by mycobacteria and fungi are more common.