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.
If an enteric organism is the suspected cause of epididymo-orchitis, fluoroquinolones are the preferred antibiotic, as they have excellent penetration into the testes. [23]
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. [24]
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.
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 [1, 3] :
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Ceftriaxone 500 mg IM in a single dose plus
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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:
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Ceftriaxone 500 mg IM in a single dose plus
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Levofloxacin 500 mg orally once 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 recommends levofloxacin 500 mg orally once a day for 10 days. Patients weighing ≥ 150 kg should also receive 1 g of ceftriaxone.
Supportive Therapy
In addition to antibiotics (except in viral epididymitis), the mainstays of supportive therapy for acute epididymitis and orchitis are as follows:
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Reduction in physical activity
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Scrotal support and elevation
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Ice packs
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Nonsteroidal anti-inflammatory drugs
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Analgesics, including nerve blocks
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Avoidance of urethral instrumentation
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Sitz baths
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. [17] 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. [25] 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. [26]
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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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.
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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.
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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.
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Scrotal sonogram showing the testes adjacent to the inflamed epididymis with a reactive hydrocele.
