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Centers for Disease Control 2006 Epididymitis Treatment GuidelinesAcute epididymitis is a clinical syndrome consisting of pain, swelling, and inflammation of the epididymis of <6 weeks. Chronic epididymitis is characterized by a 3-month or longer history of symptoms of discomfort and/or pain in the scrotum, testicle, or epididymis that is localized on clinical examination. Chronic epididymitis has been subcategorized into inflammatory chronic epididymitis, obstructive chronic epididymitis, and chronic epididymalgia (192). Among sexually active men aged <35 years, acute epididymitis is most frequently caused by C. trachomatis or N. gonorrhoeae. Acute epididymitis caused by sexually transmitted enteric organisms (e.g., Escherichia coli) also occurs among men who are the insertive partner during anal intercourse. Sexually transmitted acute epididymitis usually is accompanied by urethritis, which frequently is asymptomatic and is usually never accompanied by bacteriuria. In men aged >35 years, sexually transmitted epididymitis is uncommon. However, bacteriuria secondary to obstructive urinary disease is relatively common. In this group, nonsexually transmitted epididymitis is associated with urinary-tract instrumentation or surgery, systemic disease, or immunosuppression. Although the majority of patients can be treated on an out-patient basis, hospitalization should be considered when severe pain suggests other diagnoses (e.g., torsion, testicular infarction, or abscess) or when patients are febrile or might be noncompliant with an antimicrobial regimen. Diagnostic ConsiderationsMen who have acute epididymitis typically have unilateral testicular pain and tenderness; hydrocele and palpable swelling of the epididymis usually are present. Although the inflammation and swelling usually begin in the tail of the epididymis, they can spread to involve the rest of the epididymis and testicle. The spermatic cord is usually tender and swollen.Testicular torsion, a surgical emergency, should be considered in all cases, but it occurs more frequently among adolescents and in men without evidence of inflammation or infection. Emergency testing for torsion might be indicated when the onset of pain is sudden, pain is severe, or the test results available during the initial examination do not support a diagnosis of urethritis or urinary-tract infection. If the diagnosis is questionable, a specialist should be consulted immediately because testicular viability might be compromised. Radionuclide scanning of the scrotum is the most accurate radiologic method of diagnosis, although it is not routinely available. Color duplex doppler ultrasonography has a sensitivity of 70% and a specificity of 88% in diagnosing acute epididymitis. The evaluation of men for epididymitis should include one of the following:
Culture, nucleic acid hybridization tests, and nucleic acid amplification tests are available for the detection of both N. gonorrhoeae and C. trachomatis. Culture and nucleic acid hybridization tests require urethral swab specimens, whereas amplification tests can be performed on urine specimens. Because of their higher sensitivity, amplification tests are preferred for the detection of C. trachomatis. Depending on the risk, patients whose conditions have been diagnosed as a new STD should receive testing for other STDs. TreatmentEmpiric therapy is indicated before laboratory test results are available. The goals of treatment of acute epididymitis caused by C. trachomatis or N. gonorrhoeae are 1) microbiologic cure of infection, 2) improvement of signs and symptoms, 3) prevention of transmission to others, and 4) a decrease in potential complications (e.g., infertility or chronic pain). As an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided. See Updated recommendations, April 2007
Recommended Regimens
For acute epididymitis most likely caused by gonococcal or chlamydial infection: 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 enteric organisms or for patients allergic to cephalosporins and/or tetracyclines: Ofloxacin 300 mg orally twice a day for 10 days OR Levofloxacin 500 mg orally once daily for 10 days Follow-UpFailure to improve within 3 days of the initiation of treatment requires reevaluation of both the diagnosis and therapy. Swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively. The differential diagnosis includes tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis. Management of Sex PartnersPatients who have acute epididymitis, confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis, should be instructed to refer sex partners for evaluation and treatment if their contact with the index patient was within the 60 days preceding onset of the patient’s symptoms. Patients should be instructed to avoid sexual intercourse until they and their sex partners are cured (i.e., until therapy is completed and patient and partners no longer have symptoms). Special ConsiderationsPatients who have uncomplicated acute epididymitis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Fungi and mycobacteria, however, are more likely to cause acute epididymitis in immunosuppressed patients than in immunocompetent patients.The Most Common Urinary Diseases in Men Among men with genitourinary complaints, the three most common conditions are urethritis (which accounts for some 200,000 initial office visits each year), epididymitis (600,000 office visits), and prostatitis (approximately two million office visits for genitourinary symptoms--or one fourth of all such visits for men). This article is a review of diagnostic and management strategies for these commonly seen conditions. Amazon Store on Epididymitis Disclaimer: Information provided on this web site is for educatonal purposes only. It is not a substitute for, nor can it replace advice from your own physician. The information on this site is not to be used for diagnosing or treating any health concerns that you may have. You must see your own physician for diagnosis and treatment. Furthermore, the information on this site is never guaranteed to be 100% accurate or 100% up to date. All the side effects of mentioned treatments, drugs or therapies, cannot always be listed or be known. Errors and omissions may occur in any essay. See a competent physician for your health care needs. EpididymitisFoundation.org™ Established December 11, 2002 Website design copyright webmaster of EpididymitisFoundation.org™. All rights reserved. |
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