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Epididymitis Treatment & Management

  • Author: Christina B Ching, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 20, 2015
 

Approach Considerations

In chronic epididymitis, a 4- to 6-week trial of antibiotics for bacterial pathogens, especially against chlamydial infections, is appropriate.

With epididymitis secondary to Chlamydia trachomatis or Neisseria gonorrhoeae, treatment of all sexual partners is necessary in order to limit the rate of recurrence and to achieve maximal cure rates. Reinforce the advisability of condom use in the prevention of sexually transmitted disease.

Given the low incidence of urinary tract infections in boys with epididymitis, antibiotic therapy in prepubertal patients can be reserved for young infants and those with pyuria or positive urine culture findings. Because predicting a positive urine culture result is difficult, urine cultures should be obtained on all pediatric patients with epididymitis.[12]

Obtain immediate consultation with a urologist upon suspicion of testicular torsion, scrotal abscess, or failed medical treatment.

Orchiectomy is indicated only for patients with unrelenting epididymal pain, although up to 50% of patients still report phantom postoperative pain. Conduct an epididymotomy infrequently in patients with acute suppurative epididymitis. In rare cases, refractory pain due to chronic epididymitis and orchialgia has been managed with skeletonization of the spermatic cord via subinguinal varicocelectomy. Viral mumps has no surgical indications.

Go to Acute Epididymitis for complete information on this topic.

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Antibiotics

Guidelines from the Centers for Disease Control and Prevention (CDC) recommend the following regimen for acute epididymitis most likely caused by sexually transmitted chlamydia and gonorrhea[13, 14] :

  • Ceftriaxone 250 mg IM in a single dose plus
  • Doxycycline 100 mg orally twice a day for 10 days

For acute epididymitis most likely caused by sexually-transmitted chlamydia and gonorrhea and enteric organisms (eg, in men who practice insertive anal sex), CDC recommendations are as follows:

  • Ceftriaxone 250 mg IM in a single dose plus
  • Levofloxacin 500 mg orally once a day for 10 days or
  • Ofloxacin 300 mg orally twice a day for 10 days

For acute epididymitis most likely caused by enteric organisms (eg, cases that develop after prostate biopsy, vasectomy, and other urinary-tract instrumentation procedures, with sexually transmitted organisms ruled out) CDC recommendations are as follows:

  • Levofloxacin 500 mg orally once daily for 10 days or
  • Ofloxacin 300 mg orally twice a day for 10 days
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Supportive Therapy

In addition to antibiotics (except in viral epididymitis), the mainstays of supportive therapy for acute epididymitis and orchitis are as follows:

  • Reduction in physical activity
  • Scrotal support and elevation
  • Ice packs
  • Nonsteroidal anti-inflammatory drugs
  • Analgesics, including nerve blocks
  • Avoidance of urethral instrumentation
  • Sitz baths
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Epididymectomy and Epididymotomy

Epididymectomy

Epididymectomy was once reported to offer a limited chance (at best 50%) of relieving pain caused by chronic epididymitis.

However, a study by Siu et al found that 70% of patients who underwent epididymectomy in the face of chronic epididymal pain (in the setting of postvasectomy pain, obstruction due to radical retropubic prostatectomy or hernia repair, epididymal cysts, or chronic epididymitis) reported pain resolution.[6] In this same study, 91% of patients reported satisfaction with their decision for surgery.

Inhibition of adhesion and fibrosis after epididymectomy for chronic epididymitis improves pain relief, according to a study of 43 patients who still had pain despite conservative treatment.[15] A synthetic physical barrier (hyaluronic acid [HA]/carboxymethylcellulose [CMC]) was used to inhibit adhesion and fibrosis at the operative site in 22 patients; the remaining 21 underwent epididymectomy alone. At 24-week follow-up, 12 patients (57.1%) in the HA/CMC group were pain free, compared with 3 patients (15.8%) in the surgery-only group. HA/CMC was not associated with any adverse effects.

It has been found that epididymectomy may be more effective in men post vasectomy compared with those who have not undergone vasectomy.[16]

Despite these findings, it is still suggested that surgery be reserved only for refractory cases. Concern is that pain relief is only transient and followed by pain recurrence or transfer of symptoms to the contralateral testicle.

The possibility of fertility sequelae should also be discussed with the patient.

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Contributor Information and Disclosures
Author

Christina B Ching, MD Clinical Assistant Professor, Division of Pediatric Urology, Nationwide Children's Hospital

Christina B Ching, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Student Association/Foundation, American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Erik T Goluboff, MD Professor, Department of Urology, College of Physicians and Surgeons, Columbia University College of Physicians and Surgeons; Director of Urology, Allen Pavilion, New York Presbyterian Hospital

Erik T Goluboff, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Urological Association, Medical Society of the State of New York, New York Academy of Medicine, Phi Beta Kappa, Society for Basic Urologic Research

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Michael Franks, MD, and Badrinath R Konety, MD, to the development and writing of the source article.

References
  1. Trei JS, Canas LC, Gould PL. Reproductive tract complications associated with Chlamydia trachomatis infection in US Air Force males within 4 years of testing. Sex Transm Dis. 2008 Sep. 35(9):827-33. [Medline].

  2. Nusbaum MR, Wallace RR, Slatt LM, Kondrad EC. Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus. J Am Osteopath Assoc. 2004 Dec. 104(12):527-35. [Medline].

  3. Santillanes G, Gausche-Hill M, Lewis RJ. Are antibiotics necessary for pediatric epididymitis?. Pediatr Emerg Care. 2011 Mar. 27(3):174-8. [Medline].

  4. Raveenthiran V, Sam CJ. Epididymo-orchitis complicating anorectal malformations: collective review of 41 cases. J Urol. 2011 Oct. 186(4):1467-72. [Medline].

  5. Siegel A, Snyder H, Duckett JW. Epididymitis in infants and boys: underlying urogenital anomalies and efficacy of imaging modalities. J Urol. 1987 Oct. 138(4 Pt 2):1100-3. [Medline].

  6. Viswaroop BS, Kekre N, Gopalakrishnan G. Isolated tuberculous epididymitis: a review of forty cases. J Postgrad Med. 2005 Apr-Jun. 51(2):109-11, discussion 111. [Medline].

  7. Nason GJ, Tareen F, McLoughlin D, McDowell D, Cianci F, Mortell A. Scrotal exploration for acute scrotal pain: A 10-year experience in two tertiary referral paediatric units. Scand J Urol. 2013 Jan 3. [Medline].

  8. Rizvi SA, Ahmad I, Siddiqui MA, Zaheer S, Ahmad K. Role of color Doppler ultrasonography in evaluation of scrotal swellings: pattern of disease in 120 patients with review of literature. Urol J. 2011. 8(1):60-5. [Medline].

  9. Yu KJ, Wang TM, Chen HW, Wang HH. The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis. Chang Gung Med J. 2012 Jan-Feb. 35(1):38-45. [Medline].

  10. Waldert M, Klatte T, Schmidbauer J, Remzi M, Lackner J, Marberger M. Color Doppler sonography reliably identifies testicular torsion in boys. Urology. 2010 May. 75(5):1170-4. [Medline].

  11. Yusuf G, Sellars ME, Kooiman GG, Diaz-Cano S, Sidhu PS. Global testicular infarction in the presence of epididymitis: clinical features, appearances on grayscale, color Doppler, and contrast-enhanced sonography, and histologic correlation. J Ultrasound Med. 2013 Jan. 32(1):175-80. [Medline].

  12. Siu W, Ohl DA, Schuster TG. Long-term follow-up after epididymectomy for chronic epididymal pain. Urology. 2007 Aug. 70(2):333-5; discussion 335-6. [Medline].

  13. Taylor SN. Epididymitis. Clin Infect Dis. 2015 Dec 15. 61 Suppl 8:S770-3. [Medline].

  14. [Guideline] 2015 Sexually Transmitted Diseases Treatment Guidelines: Epididymitis. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/tg2015/epididymitis.htm. Accessed: December 19, 2015.

  15. Chung JH, Moon HS, Choi HY, et al. Inhibition of Adhesion and Fibrosis Improves the Outcome of Epididymectomy as a Treatment for Chronic Epididymitis: a multicenter, randomized, controlled, single blind study. J Urol. 2012 Dec 3. [Medline].

  16. Lee JY, Lee TY, Park HY, Choi HY, Yoo TK, Moon HS. Efficacy of epididymectomy in treatment of chronic epididymal pain: a comparison of patients with and without a history of vasectomy. Urology. 2011 Jan. 77(1):177-82. [Medline].

 
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Cross-section illustration of a testicle and epididymis. A: Caput or head of the epididymis. B: Corpus or body of the epididymis. C: Cauda or tail of the epididymis. D: Vas deferens. E: Testicle. Illustration by David Schumick, BS, CMI. Reprinted with the permission of the Cleveland Clinic Center for Medical Art and Photography © 2009. All Rights Reserved.
Color Doppler sonogram of the left epididymis in a patient with acute epididymitis. The image demonstrates increased blood flow in the epididymis resulting from the active inflammation.
Scrotal sonogram demonstrating the presence of a hydrocele and an enlarged epididymis in a patient with epididymitis. The echogenic white area is the normal testicle surrounded by the hydrocele.
Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.
 
 
 
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