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Warning:
This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:
- STD Treatment Guidelines at http://www.cdc.gov/STD/treatment
1998 Guidelines for Treatment of Sexually Transmitted Disease
Date: 01/23/98
Source: 47(RR-1);1-118
SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
EPIDIDYMITIS
Among sexually active men aged less than 35 years, epididymitis is most often caused by C. trachomatis or N. gonorrhoeae. Epididymitis caused by sexually transmitted E. coli infection also occurs among homosexual men who are the insertive partners during anal intercourse. Sexually transmitted epididymitis usually is accompanied by urethritis, which often is asymptomatic. Nonsexually transmitted epididymitis associated with urinary tract infections caused by Gram-negative enteric organisms occurs more frequently among men aged greater than 35 years, men who have recently undergone urinary tract instrumentation or surgery, and men who have anatomical abnormalities.
Although most patients can be treated on an outpatient basis, hospitalization should be considered when severe pain suggests other diagnoses (e.g., torsion, testicular infarction, and abscess) or when patients are febrile or might be noncompliant with an antimicrobial regimen.
Diagnostic Considerations
Men who have epididymitis typically have unilateral testicular pain and tenderness; hydrocele and palpable swelling of the epididymis usually are present. Testicular torsion, a surgical emergency, should be considered in all cases but is more frequent among adolescents. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection. Emergency testing for torsion may be indicated when the onset of pain is sudden, pain is severe, or the test results available during the initial examination do not enable a diagnosis of urethritis or urinary tract infection to be made. If the diagnosis is questionable, an expert should be consulted immediately, because testicular viability may be compromised. The evaluation of men for epididymitis should include the following procedures:
A Gram-stained smear of urethral exudate or intraurethral swab specimen for diagnosis of urethritis (i.e., greater than or equal to 5 polymorphonuclear leukocytes per oil immersion field) and for presumptive diagnosis of gonococcal infection.
A culture of urethral exudate or intraurethral swab specimen, or nucleic acid amplification test (either on intraurethral swab or first-void urine) for N. gonorrhoeae and C. trachomatis.
Examination of first-void urine for leukocytes if the urethral Gram stain is negative. Culture and Gram-stained smear of uncentrifuged urine should be obtained.
Syphilis serology and HIV counseling and testing.
Treatment
Empiric therapy is indicated before culture results are available. Treatment of epididymitis caused by C. trachomatis or N. gonorrhoeae will result in a) a microbiologic cure of infection, b) improvement of the signs and symptoms, c) prevention of transmission to others, and d) a decrease in the potential complications (e.g., infertility or chronic pain).
Recommended Regimens
For epididymitis most likely caused by gonococcal or chlamydial infection:
Ceftriaxone 250 mg IM in a single dose,
PLUS
Doxycycline 100 mg orally twice a day for 10 days.
For epididymitis most likely caused by enteric organisms, or for patients allergic to cephalosporins and/or tetracyclines:
Ofloxacin 300 mg orally twice a day for 10 days.
As an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided.
Follow-Up
Failure to improve within 3 days requires reevaluation of both the diagnosis and therapy. Swelling and tenderness that persist after completion of antimicrob-ial therapy should be evaluated comprehensively. The differential diagnosis includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis.
Management of Sex Partners
Patients who have epididymitis that is known or suspected to be caused by N. gonorrhoeae or C. trachomatis should be instructed to refer sex partners for evaluation and treatment. Sex partners of these patients should be referred if their contact with the index patient was within the 60 days preceding onset of symptoms in the patient.
Patients should be instructed to avoid sexual intercourse until they and their sex partners are cured. In the absence of a microbiologic test of cure, this means until therapy is completed and patient and partner(s) no longer have symptoms.
Special Considerations
HIV Infection
Patients who have uncomplicated epididymitis and also are infected with HIV should receive the same treatment regimen as those who are HIV-negative. Fungi and mycobacteria, however, are more likely to cause epididymitis in immunosuppressed patients than in immunocompetent patients.
