Approach
The general goals in the treatment of acute epididymitis are:[15]
Symptomatic relief
Eradication of infection if present
Prevention of transmission to others (sexually transmitted epididymitis)
Prevention of potential complications (e.g., abscess formation, infertility, or chronic pain/epididymitis).
Symptomatic relief
Bed rest, scrotal elevation, and simple analgesia are the main supportive therapies in the treatment of acute epididymitis regardless of the etiology of the condition. Such measures are recommended until signs of local inflammation or fever have resolved.[15] If the patient is systemically ill with high-grade fever, admission to the hospital for intravenous antibiotics and fluids is indicated. In drug-induced acute epididymitis due to amiodarone, dose reduction or discontinuation of the drug results in rapid resolution of the symptoms. Vasculitic epididymitis resolves with conservative measures and treatment of the underlying cause. This may necessitate specialist input from a rheumatologist, as severe cases of vasculitis can require treatment with systemic corticosteroids and immunosuppressive agents.
Eradication of infection
Most international guidelines for the treatment of epididymitis have been based on studies that are more than 10 years old.[14] More recent studies, however, have highlighted a shift in the age distribution, causative organism, and the importance of sexual activity on the etiology.
In cases where bacterial infection is the presumed causative factor, empirical antibiotic treatment is indicated before laboratory tests are available. The choice of antibiotics will depend on the age of the patient and their associated risk factors, including history of unprotected intercourse, recent urinary tract instrumentation, bladder outflow obstruction, or systemic disease/immunosuppression.[26] Once test results are available, the antibiotics can be adjusted to target the causative organism(s).
In cases where epididymitis may be caused by gonococcal or chlamydial infection, ceftriaxone plus doxycycline is recommended as initial empiric therapy.[15] For men who practise insertive anal sex, enteric organisms may also be a cause of epididymitis, and treatment with ceftriaxone plus levofloxacin should be given.[15] In patients where gonorrhea is considered likely (presence of risk factors: a purulent urethral discharge, known contact of a gonorrheal infection, men who have sex with men), the International Union against Sexually Transmitted Infections (IUSTI) European guideline on epididymo-orchitis recommends addition of azithromycin to ceftriaxone and doxycycline.[26] The Centers for Disease Control and Prevention (CDC) updated its guidance on uncomplicated gonorrheal infection to ceftriaxone monotherapy; but recommendations for complicated infections (such as epididymitis) remain unchanged and require combination therapy with ceftriaxone plus doxycycline.[15] Because of high resistance rates, fluoroquinolones are no longer recommended for suspected or confirmed gonococcal epididymitis.
The recognition of Mycoplasma genitalium as a potential pathogen in epididymitis has led to an update in some guideline recommendations, such that where M genitalium testing has been performed, and the organism identified, antibiotic treatment should be chosen based on resistance testing. IUTSI recommends testing for macrolide resistance in all confirmed M genitalium cases.[26][30] Complicated M genitalium infections such as epididymitis should be treated first-line with the fluoroquinolone moxifloxacin.[30] Patients with epididymitis and a known partner who has tested positive for M genitalium should also be treated with moxifloxacin.[29]
For acute epididymitis most likely caused by enteric organisms (recent urinary tract instrumentation, systemic disease, or immunosuppression), the use of levofloxacin is recommended.[15]
Systemic fluoroquinolone antibiotics, such as moxifloxacin and levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[39]
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
Other causes are unusual. Mumps epididymitis is treated with supportive care. Tuberculous epididymitis should be treated with systemic antibiotics according to local guidelines, due to highly variable tuberculosis strains and antibiotic resistance patterns.
Prevention of potential complications
Prompt treatment and supportive measures will limit the overall severity of the condition and thereby reduce the risk of developing complications. Prompt empirical antibiotic therapy may prevent abscess formation and thus avoid the need for hospitalization and surgery.[40] Testicular ischemia/infarction is a rare complication of severe epididymitis, which may lead to problems with subfertility/infertility. Although up-to-date data are limited, the use of corticosteroids has not been shown to confer any significant benefit in reducing the long-term sequelae of epididymal obstruction secondary to inflammation.[41] The development of chronic pain/epididymitis following acute epididymitis is rare, and little is known about its etiology and pathogenesis.[42]
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