The patient’s presentation is consistent with acute epididymitis. Empiric treatment includes ceftriaxone plus doxycycline.
Epididymitis is the most common cause of scrotal pain in adults males. It is typically caused by a retrograde bacterial infection, with N. gonorrheae and C. trachomatis being the most common pathogens in men 14-35 years of age. Empiric treatment is single dose intramuscular ceftriaxone and oral doxycycline for 10 days. In males younger than 14 or older than 35, urinary tract pathogens such as E. coli are most common and treatment options include levofloxacin for 10 days. Risk factors for the development of epididymitis include sexual activity, strenuous physical activity, bicycling, and prolonged periods of sitting. Symptoms usually include a gradual onset of scrotal pain with swelling, possible urinary tract symptoms, and fever.
Trojian et al. discuss epididymitis and orchitis diagnosis and management, as well as the differential for scrotal pain. They emphasize that it is important to distinguish epididymitis from testicular torsion, which is often a surgical emergency. Doppler ultrasonography can be an important diagnostic tool in addition to history and physical in distinguishing these diagnoses. Besides antibiotics, symptom relief for epididymitis includes analgesics, scrotal elevation, limitation of activity, and use of cold packs.
Tracy et al. discuss possible causes of noninfectious epididymitis, which include sarcoidosis, Behcet disease, Henoch-Schonlein purpura, and medication-induced (e.g. amiodarone). Diagnostic testing for infectious epididymitis also can include a gram stain of urethral exudate, PCR for chlamydia, and direct fluorescent antibody testing.
Figure A shows an enlarged, thickened epididymis consistent with epididymitis. Illustration A is an ultrasound showing Doppler flow. Note that in addition to an enlarged epididymis, there is increased blood flow. This is in contrast to testicular torsion, where the testicle appears normal with decreased blood flow.
Answer 2: Levofloxacin is recommended for patients who are under 14 or over 35 years of age to cover common urinary tract organisms.
Answer 3: This is the management of mumps if the patient has not yet received the vaccine.
Answer 4: Referral to a urologist or a local ED may be indicated if testicular torsion is suspected.
Answer 5: CT abdomen and pelvis is not indicated at this time.
Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. Am Fam Physician. 2009 Apr 1;79(7):583-7.
PMID:19378875 (Link to Abstract)
Tracy CR, Steers WD, Costabile R. Diagnosis and management of epididymitis. Urol Clin North Am. 2008 Feb;35(1):101-8; vii.
PMID:18061028 (Link to Abstract)
USMLE Step 2 CK Qbook 4th ed. Daugherty, Stephen R. New York: Kaplan Publishing, 2008.