eMedicine Specialties > Emergency Medicine > Genitourinary
Epididymitis: Treatment & Medication
Updated: Sep 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
Patients with testicle or scrotal pain require immediate evaluation in order to identify and quickly treat potential cases of testicular torsion. Although most cases of torsion occur in patients aged 12-18 years, testicular torsion should be considered in any patient aged 12-30 years who presents with a scrotal complaint.
- Obtain immediate urologic consultation if unable to clearly differentiate testicular torsion from epididymitis or other scrotal pathology.
- Antibiotic therapy
- Analgesics for pain control
- Supportive care
- Scrotal elevation and support
- Ice pack
- Spermatic cord block (possibly)
Consultations
Consult a urologist immediately if torsion is a possibility. Testicular torsion is a clinical diagnosis, and consultation should not be delayed for the performance of additional ancillary studies. Otherwise, most cases of epididymitis can be managed on an outpatient basis with follow-up with a urologist scheduled within 3-7 days. All pediatric cases of epididymitis require immediate consultation because of the high incidence of associated genitourinary anomalies.
Medication
Antibiotics should be used in all cases of epididymitis, regardless of a negative urinalysis or the urethral Gram stain result. Nonsteroidal anti-inflammatory agents or narcotic analgesics also generally are prescribed to patients with epididymitis.
Antibiotics
Empiric coverage varies with the patient's age and sexual history.
Prepubertal patients and older men require empiric coverage for coliform bacteria (enteric gram-negative bacilli or Pseudomonas). Both of these patient populations may be treated with trimethoprim sulfamethoxazole (TMP-SMZ).
Sexually active men need empiric coverage for C trachomatis and N gonorrhoeae, usually with ceftriaxone and doxycycline or azithromycin.
Fluoroquinolones are no longer recommended to treat gonorrhea in the United States. This recommendation was based on an analysis of data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP shows an 11-fold increase in the proportion of fluoroquinolone-resistant gonorrhea (QRNG) in heterosexual men, increasing from 0.6% in 2001 to 6.7% in 2006.9 This limits treatment of gonorrhea to drugs in the cephalosporin class. Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.
Ceftriaxone (Rocephin)
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult
250-1000 mg IM once
Pediatric
Infants and children: 50-75 mg/kg/d IV divided q12h; not to exceed 2 g/d
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and those allergic to penicillin
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Inhibits protein synthesis and bacterial growth by binding with the 30S and, possibly, the 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid for 10-14 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d in 1-2 divided doses; not to exceed 200 mg/d
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 one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Azithromycin (Zithromax)
Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. Indicated for chlamydial and gonorrheal infections of the genital tract.
Adult
1 g PO once
Pediatric
<6 months: Not established
>6 months: 10 mg/kg PO day 1; 5 mg/kg PO qd days 2-5
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
Sudden death may occur when azithromycin is taken concurrently with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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
Trimethoprim, sulfamethoxazole (Septra DS, Bactrim DS)
Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid. This results in the inhibition of bacterial growth.
The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Adult
1 tab PO bid for 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 8 mg/kg TMP and 40 mg/kg SMZ qd
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
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
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Ciprofloxacin (Cipro)
An alternative to Septra DS; a bactericidal antibiotic that inhibits bacterial DNA synthesis, and, consequently, growth, by inhibiting DNA-gyrase in susceptible organisms.
Indicated for pseudomonal infections and those that are due to multi-drug-resistant gram-negative organisms. Duration of treatment depends upon severity of infection. Generally, continue therapy for at least 2 d after the signs and symptoms of infection have disappeared. Usual treatment duration is 7-14 d.
Adult
500 mg PO bid for 10-14 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
More on Epididymitis |
| Overview: Epididymitis |
| Differential Diagnoses & Workup: Epididymitis |
 Treatment & Medication: Epididymitis |
| Follow-up: Epididymitis |
| References |
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References
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Further Reading
Keywords
epididymitis, epididymo-orchitis, intrascrotal inflammation, Escherichia coli, Chlamydia trachomatis, Neisseria gonorrhoeae, chemical epididymitis, epididymal abscess, testicular abscess, sterility, peritubular fibrosis, sexually transmitted epididymitis, urethritis, scrotal pain, scrotal edema, urinary frequency, urinary urgency, dysuria, urinary retention, urethral discharge, scrotal abscess, Prehn sign, candidal epididymitis
