Section 4-3: Canadian Guidelines on Sexually Transmitted Infections – Management and treatment of specific syndromes – Epididymitis

Section 4 - Management and Treatment of Specific Syndromes

Epididymitis

Definition

  • Epididymitis can be defined as inflammation of the epididymis manifested by a gradual onset of unilateral testicular pain (sometimes bilateral pain) and swelling often with tenderness of the epididymis and vas deferens and occasionally with erythema and edema of the overlying skin.
  • The term epididymo-orchitis is primarily used when inflammation occurs in both the epididymis and the testes together.Footnote 1

EtiologyFootnote 2

  • Before tests for detecting Chlamydia trachomatis were available, the cause of most cases of acute epididymitis was unknown. Subsequent studies have shown that epididymitis is primarily an infective condition.
  • In men under 35 years of age, sexually transmitted infection (STI) accounts for ⅔ of epididymitis (47% Chlamydia trachomatis and 20% Neisseria gonorrhoeae). In men over 35 years of age, 75% of cases can be attributed to coliforms or pseudomonas. Isolation of Chlamydia trachomatis or Neisseria gonorrhoeae is unusual.
  • The determination of the possible etiologic agent should always be based on the evaluation of the risk of the individual having acquired a sexually transmitted agent.
  • In children and young adults, it is important to consider non-infectious causes of scrotal swelling, such as trauma, torsion of the testicle and tumour.
  • Rare causes of clinical sterile acute epididymitis include amiodarone therapy, vasculitis, polyarteritis nodosa, Behçet disease and Henoch-Schönlein purpura. 
  • A proportion of cases are idiopathic.
Table 1. Microbial etiology and predisposing factors in acute epididymitisFootnote 3
Age group Etiology and predisposing factors
Prepubertal children
  • Usual etiology: coliforms, P. aeruginosa
  • Unusual etiology: hematogenous spread from primary infected site
  • Predisposing factors: underlying genitourinary pathology
Men under 35
  • Usual etiology: C. trachomatis, N. gonorrhoeae
  • Unusual etiology: coliforms or P. aeruginosa, Mycobacterium tuberculosis
  • Predisposing factors: sexually transmitted urethritis
Men over 35
  • Usual etiology: coliforms or P. aeruginosa
  • Unusual etiology: N. gonorrhoeae, C. trachomatis, Mycobacterium tuberculosis
  • Predisposing factors: underlying structural pathology or chronic bacterial prostatitis

Epidemiology

  • Accurate data on acute epididymitis are lacking. Therefore, the incidence in the general population is unknown. In a large retrospective study of US military personnel, 70% of cases were in those aged 20–39 years. Footnote 4
  • In adolescents with epididymitis, sexual history should be assessed, as the cause may be an STI.
  • Coliforms may be a frequent cause of acute epididymitis in sexually active men of all ages who practice condomless insertive anal intercourse.

Prevention and Control

  • At the time of diagnosis of suspected sexually acquired epididymitis, safer sex practices should be reviewed.
  • Information should be provided regarding the efficacy of barrier methods such as condoms.
  • People with epididymitis and their partners should abstain from any sexual activity without barrier protection until treatment of the person and all current partners is complete (completion of a multiple-dose treatment or seven days after single-dose therapy) and symptoms have resolved.

ManifestationsFootnote 5,Footnote 6

  • Acute epididymitis usually present with unilateral testicular pain and tenderness.
  • The onset of pain is generally gradual.
  • In sexually transmitted epididymitis, symptoms of urethritis or a urethral discharge may be present, however urethritis is often asymptomatic.

Signs of acute epididymitis may include:

  • Tenderness to palpation on the affected side
  • Palpable swelling of the epididymis
  • Urethral discharge
  • Hydrocele
  • Erythema and/or edema of the scrotum on the affected side
  • Fever

DiagnosisFootnote 5

  • Evaluation and specimen collection for epididymitis should include the following:
    • Collection of urethral swab for Gram stain.
    • Collection of specimens for identification of N. gonorrhoeae and C. trachomatis (urethral swab or first-void urine according to available laboratory techniques).
      • Depending on the clinical situation, consider collecting samples for both culture and NAAT for the detection of N. gonorrhoeae. This is strongly recommended in symptomatic gay, bisexual and other men who have sex with men (gbMSM) or in situations where there is increased probability of treatment failure.
    • Collection of mid-stream urine for microscopy and culture.
  • Testicular torsion should be considered in all cases, as it is a surgical emergency: testicular viability may be compromised.
    • Torsion is often associated with sudden and severe onset of pain.
    • Torsion is more frequent in men less than 20 years of age, but it can occur at any age.
    • If it can be arranged without delay, a Doppler ultrasound may be useful to help differentiate testicular torsion from epididymitis.
    • If diagnosis remains uncertain, consult a specialist immediately.
  • There is no role for epididymal aspiration in routine clinical practice. It may be useful in recurrent infection that fails to respond to therapy or in individuals with suspected abscess formation.

Management and Treatment

See Table 2, below, for treatment recommendations for acute epididymitis.

Table 2. Recommended treatment of acute epididymitisFootnote 5Footnote 10

Epididymitis most likely caused by an STI (chlamydial and/or gonococcal infection)

Doxycycline 100 mg PO bid for 10–14 days [A-l]

PLUS

Ceftriaxone 250 mg IM in a single doseTable 2 - Footnote *Table 2 - Footnote §

[A-l]

Epididymitis most likely caused by an STI and enteric organisms (co-infection)

Levofloxacin 500 mg PO once a day for 10 days [B-III]

PLUS

Ceftriaxone 250 mg IM in a single dose [A-I]
Note: This treatment is recommended for men who practice condomless insertive anal sex.

Due to the rapid increase in quinolone resistant Neisseria gonorrhoeae, quinolones are no longer preferred drugs for the treatment of gonococcal infections in Canada, and should not be given unless local resistance rates are known to be under 5%.

Quinolones may be considered as an alternative treatment option ONLY IF:

  • antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated; OR
  • where antimicrobial testing is not available, a test of cure will be done.

Note: Consult an experienced colleague when there are contraindications to the recommended treatment regimens.

Consideration for Other STIs

  • Depending on sexual history, gonococcal and/or chlamydial infections should be considered as the etiology of acute epididymitis in all sexually active men with acute epididymitis, especially those under age 35.
  • Consideration for testing for other STIs, including HIV, should be made according to sexual history and the presence of risk factors for specific infections.

Reporting and Partner Notification

  • Individuals with infections that are reportable according to provincial and territorial laws and regulations should be reported to the local public health authority.
  • Local public health authorities are available to assist with partner notification and help with referral for counselling, clinical evaluation, testing and treatment.
  • When an STI is the most likely cause of acute epididymitis, all sexual partners from 60 days prior to symptom onset or the date of specimen collection should be located, clinically evaluated, tested and treated regardless of clinical findings and without waiting for test results.

Follow-up

  • All individuals treated for epididymitis should improve within 48 hours of initiation of treatment; those that do not should be reassessed to evaluate the initial diagnosis and treatment.

Tests of cure recommendations depend on the identified pathogens.

Special Considerations

  • A condition described as “chronic epididymitis” has been described in the literature. Footnote 11 Although defined by the author as the presence of “symptoms of discomfort and/or pain at least 3 months in duration in the scrotum, testicle or epididymis localized to one or each epididymis on clinical examination,” there is no clear natural history of the condition. The authors conclude that further studies on the epidemiology, etiology and pathogenesis of this condition are needed.

References

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