eMedicine Specialties > Urology > Common Problems of the Testicle
Epididymitis: Treatment & Medication
Updated: Jun 12, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- 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
- Anti-inflammatory agents
- Analgesics, including nerve blocks
- Avoidance of urethral instrumentation
- Sitz baths
- In chronic epididymitis, a 4- to 6-week trial of antibiotics for bacterial pathogens, especially against chlamydial infections, is appropriate.
Surgical Care
- Scrotal exploration
- Perform a scrotal exploration if torsion or tumor cannot be ruled out and for the complications of acute epididymitis and orchitis (eg, abscess, pyocele, testicular infarction).
- Diagnosis of intrascrotal disorders is often confirmed during orchiectomy.
- Epididymectomy
- This procedure was once reported to offer a limited chance (at best 50%) of relieving pain caused by chronic epididymitis. However, a recent 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, chronic epididymitis) reported pain resolution.3 In this same study, 91% of patients reported satisfaction with their decision for surgery.
- Despite these findings, surgery is still suggested to be reserved for only refractory cases.
- The possibility of fertility sequelae should also be discussed with the patient.
- Pain relief is often transient and is followed by pain recurrence or transfer of symptoms to the contralateral testicle.
- Epididymotomy: Conduct this procedure infrequently in patients with acute suppurative epididymitis.
- Viral mumps has no surgical indications.
- In rare cases, refractory pain due to chronic epididymitis and orchalgia has been managed with skeletonization of the spermatic cord via subinguinal varicocelectomy.
- Orchiectomy is indicated only for unrelenting epididymal pain, although up to 50% of patients still report phantom postoperative pain.
Consultations
- Obtain immediate consultation with a urologist upon suspicion of testicular torsion or failed medical treatment.
Medication
Nonspecific bacterial epididymitis and orchitis (often assumed in patients >35 y) require empiric treatment that covers coliform bacteria (eg, levofloxacin or ofloxacin) for 10 days. Systemic illness warrants hospitalization and coverage with intravenous ampicillin and gentamicin. Additionally, use blood and urine cultures to guide therapy.
Consider sexually transmitted epididymitis in men aged 15-35 years who are sexually active; however, STDs must also be considered in children and older adults based on history and context. Empiric therapy consists of treatment for N gonorrhoeae and Chlamydia trachomatis infections with a one-time dose of intramuscular ceftriaxone followed by oral doxycycline for 10 days. A single dose of azithromycin is an alternative to doxycycline, which may improve compliance.
Fluoroquinolones are no longer recommended to treat gonococcal infection because of the high rate of resistant organisms. Chlamydial infections may be treated with levofloxacin or ofloxacin, especially if the patient is allergic to penicillin; however, ciprofloxacin and older fluoroquinolones are discouraged because of their incomplete coverage. Nongonococcal infections are treated with doxycycline or, alternatively, azithromycin or tetracycline. Both sexual partners must be treated. In a British study, up to 80% of female partners of young men diagnosed with acute epididymitis tested positive for chlamydia.
Antitubercular triple therapy consists of rifampin, isoniazid, and pyrazinamide for 6 months. Ethambutol is added in highly drug-resistant areas. In patients with BCG-related epididymitis, isoniazid and rifampin can be used alone because these strains are resistant to pyrazinamide. Brucella epididymitis is treated with 6 weeks of doxycycline.
Chronic epididymitis may respond to tricyclics and anticonvulsants (gabapentin); however, these are not supported by randomized placebo-controlled trials.
Amiodarone epididymitis usually responds to dosage reduction or discontinuation. Mumps orchitis and traumatic and idiopathic epididymitis require no specific therapy other than supportive measures. The efficacy of alpha interferon and gonadotropin-releasing hormone (GRH) therapy in the treatment of mumps orchitis is currently unproven.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Adult
250 mg IM qd (one-time dose), or divided bid; not to exceed 4 g/d
Pediatric
Not established
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and penicillin allergy
Doxycycline (Doryx, Vibramycin)
Treatment for C trachomatis infection. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid for 10 days
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Used for treatment of gonococcal infections, chlamydia, or both.
Adult
C trachomatis infection: 1 g PO as single dose
Chlamydia and gonococcal infection: 2 g PO as single dose
Pediatric
Not established
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Ofloxacin (Floxin)
Penetrates prostate well and is effective against C trachomatis. It is no longer recommended to use fluoroquinolones to treat gonococcal infections secondary to a high rate of resistance. A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
Adult
400 mg PO bid for 14 d
Pediatric
Not established
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Ciprofloxacin (Cipro)
For bacterial infections. No longer recommended for gonococcal and nongonococcal infections, such as chlamydia, given their incomplete coverage and increased rate of resistance.
Adult
500 mg PO bid for 14 d
Pediatric
Not established
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
For empiric treatment of nonspecific bacterial infection.
Adult
1 tab PO bid for 14 d
Pediatric
Not established
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Levofloxacin (Levaquin)
Excreted in the urine and is effective against C trachomatis. It is no longer recommended to use fluoroquinolones to treat gonococcal infections secondary to a high rate of resistance. A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
Adult
500 mg PO qd for 10 days
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Antituberculous drugs
These agents are used to treat tuberculous epididymo-orchitis.
Rifampin (Rifadin, Rimactane)
Part of the triple-drug regimen. For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed from conversion to sputum culture negativity.
Adult
450 mg PO qd for 2 mo
900 mg PO qd for additional 4 mo
Pediatric
Not established
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Isoniazid (Laniazid, Nydrazid)
An isonicotinic acid hydrazide (INH), which is part of the triple-drug regimen.
Adult
300 mg PO qd for 2 mo
600 mg PO qd for additional 4 mo
Pediatric
Not established
Higher incidence of isoniazid-related hepatitis can occur with daily alcohol ingestion; aluminum salts may decrease isoniazid serum levels (administer 1-2 h before taking aluminum salts); may increase anticoagulants effects with coadministration; may inhibit metabolic clearance of benzodiazepines; carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase adverse CNS effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram; coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin
Documented hypersensitivity; previous isoniazid-associated hepatic injury or other severe adverse reactions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations during isoniazid therapy are recommended even when visual symptoms do not occur
Pyrazinamide
Pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on concentration of drug attained at site of infection; mechanism of action is unknown. Part of the triple-drug regimen.
Adult
25 mg/kg/d PO for first 2 mo only
Pediatric
Not established
None reported
Documented hypersensitivity; severe hepatic damage, acute gout
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only in combination with other effective antituberculous agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline serum uric acid determinations; discontinue drug if signs of hyperuricemia with acute gouty arthritis; perform baseline LFTs (closely monitor in liver disease); discontinue pyrazinamide if signs of hepatocellular damage appear; caution in history of diabetes mellitus
More on Epididymitis |
| Overview: Epididymitis |
| Differential Diagnoses & Workup: Epididymitis |
 Treatment & Medication: Epididymitis |
| Follow-up: Epididymitis |
| Multimedia: Epididymitis |
| References |
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References
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Further Reading
Keywords
epididymitis, epididymo-orchitis, orchitis, epididymis, testicular torsion, bladder outlet obstruction, BOO, urethral stricture, ectopic ureter, ectopic vas deferens, prostatic utricle, urethral duplication, posterior urethral valves, urethrorectal fistula, detrusor sphincter dyssynergia, vesicoureteral reflux, benign prostatic hyperplasia, BPH, sexually transmitted diseases, STDs, inflammation of the epididymis, epididymal pain, acute epididymitis, chronic epididymitis, urethritis, prostatitis, tuberculous epididymitis, genitourinary tuberculosis, genitourinary TB, mumps orchitis, urogenital malformations, scrotal pain, scrotal swelling, urethral discharge, parotiditis, funiculitis, Prehn sign, reactive hydrocele, beading of the vas deferens, scrotal cellulitis, urinary coliforms, Chlamydia, Neisseria gonorrhoeae, Ureaplasma urealyticum, Treponema pallidum, Trichomonas, Gardnerella vaginalis, sterile reflux, urethro-vasal reflux, amiodarone epididymitis, trauma to the scrotum, brucellosis, coccidioidomycosis, blastomycosis, cytomegalovirus, candidiasis, coxsackievirus type A, varicella, echoviral infections
