Epididymo-orchitis Empiric Therapy 

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General recommendations and empiric therapeutic regimens for epididymo-orchitis are provided below. Guidelines are based on epidemiology and therefore the appropriate choice of antibiotics requires a clinical assessment of the most likely etiology. The following are summarized below [1, 2, 3, 4, 5] :

Acute epididymo-orchitis may be bacterial, nonbacterial, noninfectious, or idiopathic in origin. [6] Bacterial epididymo-orchitis tends to be caused by either urinary tract pathogens or by a sexually transmitted pathogen. [7]

Empiric antibiotic therapy is recommended only for presumed bacterial epididymitis and should be started before microbiological identification of the pathogen. [7]

STI-associated epididymo-orchitis is more likely in men younger than 35 years with more than one partner in the past 12 months, particularly if urethral discharge is present. [8]

Treatment is aimed at eradication of Neisseria gonorrhoeae and Chlamydia trachomatis and consists of the following:

Note that the dose of ceftriaxone has been increased from 125 mg (US guidelines) and 250 mg (European, New Zealand guidelines) that were recommended in earlier guidelines, owing to increased resistance of N gonorrhoeae to ceftriaxone. [7, 9, 10]

If a STI is suspected, advise the patient to use condoms or abstain from sex for 7 days after treatment is initiated. [8] Sexual partners should be referred for evaluation and treatment to eliminate the possibility of reinfection.

Epididymo-orchitis due to infection with gram-negative enteric organisms is most likely in men older than 35 years with a low-risk sexual history, with recent urological instrumentation or urinary tract infection, or with positive urine dipstick for leukocytes and nitrites. If an enteric organism is suspected, fluoroquinolones are the preferred antibiotic, as they have excellent penetration into the testes. [7, 11] Recommended regimens include the following:

Ciprofloxacin 500 mg PO BID for 10-14d or

Levofloxacin 500 mg PO daily for 10d or

Ofloxacin 200 mg PO BID for 14d or

Trimethoprim-sulfamethoxazole (160/800 mg) one DS tablet PO BID for 10d or

Amoxicillin-clavulanate 500 mg TID for 10d

Options include the following:

Trimethoprim-sulfamethoxazole 3-6 mg/kg PO q12h for 10d or

Amoxicillin-clavulanate 15-20 mg/kg PO q12h for 10d

Approaches include the following:

Haecker FM, Hauri-Hohl A, von Schweinitz D. Acute epididymitis in children: a 4-year retrospective study. Eur J Pediatr Surg. 2005 Jun. 15(3):180-6. [Medline].

Nickel JC, Teichman JM, Gregoire M, Clark J, Downey J. Prevalence, diagnosis, characterization, and treatment of prostatitis, interstitial cystitis, and epididymitis in outpatient urological practice: the Canadian PIE Study. Urology. 2005 Nov. 66(5):935-40. [Medline].

Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008 Feb. 35(1):101-8; vii. [Medline].

Aydemir H, Budak G, Budak S, Celik O, Yalbuzdag O, Keles I. Different presentation types of primary Brucella epididimo-orchitis. Arch Ital Urol Androl. 2015 Jul 7. 87 (2):151-3. [Medline].

Savasci U, Zor M, Karakas A, Aydin E, Kocaaslan R, Oren NC, et al. Brucellar epididymo-orchitis: a retrospective multicenter study of 28 cases and review of the literature. Travel Med Infect Dis. 2014 Nov-Dec. 12 (6 Pt A):667-72. [Medline].

Luzzi GA, O’Brien TS. Acute epididymitis. BJU Int. 2001 May. 87(8):747-55. [Medline].

Walker NA, Challacombe B. Managing epididymo-orchitis in general practice. Practitioner. 2013 Apr. 257(1760):21-5, 2-3. [Medline].

New Zealand Sexual Health Society. Epididymo-Orchitis. Available at http://www.nzshs.org/guidelines/Epididymo-orchitis-guideline.pdf. Accessed: August 20, 2013.

[Guideline] Lazaro N. Sexually Transmitted Infections in Primary Care. Second Edition 2013. British Association for Sexual Health and HIV (BASHH). Available at http://www.bashh.org/documents/Sexually%20Transmitted%20Infections%20in%20Primary%20Care%202013.pdf. Accessed: July 2013.

Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17. 59:1-110. [Medline].

Fehily SR, Trubiano JA, McLean C, Teoh BW, Grummet JP, Cherry CL, et al. Testicular loss following bacterial epididymo-orchitis: Case report and literature review. Can Urol Assoc J. 2015 Mar-Apr. 9 (3-4):E148-51. [Medline].

Yagil Barazani, MD Associate Physician, Department of Urology, The Permanente Medical Group

Disclosure: Nothing to disclose.

Christina B Ching, MD Clinical Assistant Professor, Division of Pediatric Urology, Nationwide Children’s Hospital

Christina B Ching, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Student Association/Foundation, American Urological Association

Disclosure: Nothing to disclose.

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Epididymo-orchitis Empiric Therapy 

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