STI-associated syndromes guide: Epididymitis

This guide provides an overview of the management and empiric treatment of sexually transmitted infection (STI) - associated epididymitis, which is an inflammation of the epididymis and vas deferens.

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Public health importance

Acute epididymitis is the most common cause of scrotal pain in adultsFootnote 1 and is frequently associated with an STIFootnote 2Footnote 3.

Common STI-associated etiology

The probability that epididymitis is caused by a sexually transmitted infection (STI), another infection or a non-infectious cause depends on a person's sexual practises and risk factors for a sexually transmitted and blood-borne infection (STBBI). Acute epididymitis is primarily an infective conditionFootnote 3Footnote 4. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the most common causes of acute epididymitis in sexually active peopleFootnote 2Footnote 3.

Adults with STBBI risk factors

Adults without STBBI risk factors

Enteric bacteria may be a frequent cause of acute epididymitis in sexually active individuals (in all age groups) who practice condomless insertive anal sex Footnote 3.

Clinical manifestations

Symptoms and signs of epididymitis include:

Symptoms of urethritis may be present in epididymitis caused by a STI.

Consider a diagnosis of testicular torsion in all cases of acute and unilateral testicular pain. Testicular torsion is often associated with sudden and severe onset of pain and requires urgent assessment and management because testicular viability can be compromised. It can occur at any age, but is more frequent in individuals under 20 years.

In children and young adults, it is important to consider non-infectious causes of scrotal swelling, such as trauma. Low grade pain with progression over months or weeks may be indicative of a tumour.

Diagnostic testing

Empiric treatment and management

The decision to treat empirically or to wait for test results should reflect the:

Empiric treatment for acute epididymitis when an STI is suspected (CT, GC or both) Empiric treatment for acute epididymitis when an STI (CT, GC or both) and enteric co-infection is suspected

Ceftriaxone 250 mg IM in a single dose [A-I]
plus
Doxycycline 100 mg PO BID for 10 to 14 days [A-I]

Ceftriaxone 250 mg IM in a single dose
plus
Levofloxacin 500mg PO once daily for 10 days[B-III]

Note: This treatment is recommended for individuals who have condomless insertive anal sex.

Consider urgent consultation with an experienced colleague and hospitalization when severe pain or high fever suggests another diagnosis or complicated infection (testicular torsion, testicular infarction, abscess, necrotizing fasciitis)Footnote 6.

Follow-up

Evaluate response to treatment 48 hours after initiation. If there is no clinical improvement, reassess the diagnosis and treatment.

The need for test of cure (TOC) depends on which pathogen is confirmed by laboratory testing. Refer to the etiology-specific guide.

Reporting and partner notification

When treatment is indicated for an STI: notify, evaluate, test and treat (as appropriate) sexual partners. Refer to the etiology-specific guide(s) for guidance on reporting and partner notification.

References

Footnote 1

Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician 2009;79(7): 583-587

Return to footnote 1 referrer

Footnote 2

Michel V, Pilatz A, Hedger MP, Meinhardt A. Epididymitis: revelations at the convergence of clinical and basic sciences. Asian J Androl 2015;17(5):756-763

Return to footnote 2 referrer

Footnote 3

Luzzi GA, O'Brien TS. Acute epididymitis. BJU Int 2001 May;87(8):747-755.

Return to footnote 3 referrer

Footnote 4

Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am 2008;35(1):101-108.

Return to footnote 4 referrer

Footnote 5

Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR Recomm Rep 2002;51(RR-6):1-78.

Return to footnote 5 referrer

Footnote 6

Institut national d'excellence en santé et en services sociaux (INESSS). Traitement pharmacologique des infections transmissibles sexuellement et par le sang-Approche syndromique. INESSS 2018.

Return to footnote 6 referrer

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