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This document is being maintained for historical purposes, but is now out of date.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

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

EPIDIDYMITIS
     
     Among men less than 35 years of age, epididymitis is most
often caused by N. gonorrhoeae or C. trachomatis. Epididymitis
caused by sexually transmitted Escherichia coli infection also
occurs among homosexual men who are the insertive partners during
anal intercourse. Sexually transmitted epididymitis is usually
accompanied by urethritis, which is often asymptomatic. Nonsexually
transmitted epididymitis associated with urinary tract infections
caused by Gram-negative enteric organisms is more common among men
greater than 35 years of age, and among men who have recently
undergone urinary tract instrumentation or surgery.

Diagnostic Considerations
     
     Men with epididymitis typically have unilateral testicular
pain and tenderness; palpable swelling of the epididymis is usually
present. Testicular torsion, a surgical emergency, should be
considered in all cases but is more frequent among adolescents.
Emergency testing for torsion may be indicated when the onset of
pain is sudden, pain is severe, or test results available during
the initial visit do not permit a diagnosis of urethritis or
urinary tract infection. The evaluation of men for epididymitis
should include the following procedures:

--   A Gram-stained smear of urethral exudate or intraurethral swab
     specimen for N. gonorrhoeae and for NGU ( greater than or equal to
     5 polymorphonuclear leukocytes per oil immersion field),

--   A culture of urethral exudate or intraurethral swab specimen
     for N. gonorrhoeae,

--   A test of an intraurethral swab specimen for C. trachomatis,

--   Culture and Gram-stained smear of uncentrifuged urine for
     Gram-negative bacteria.

Treatment

     Empiric therapy is indicated before culture results are
available. Treatment of epididymitis caused by C. trachomatis or N.
gonorrhoeae will result in microbiologic cure of infection, improve
signs and symptoms, and prevent transmission to others.

     Patients with suspected sexually transmitted epididymitis
should be treated with an antimicrobial regimen effective against
C. trachomatis and N. gonorrhoeae; confirmation of these agents by
testing will assist in partner notification efforts, but current
tests for C. trachomatis are not sufficiently sensitive to exclude
infection with that agent.

Recommended Regimen -
     Ceftriaxone 250 mg IM in a single dose
                   and
     Doxycycline 100 mg orally 2 times a day for 10 days.

     The effect of substituting the 125 mg dose of ceftriaxone
recommended for treatment of uncomplicated N. gonorrhoeae, or the
azithromycin regimen recommended for treatment of C. trachomatis,
is unknown.

     As an adjunct to therapy, bed rest and scrotal elevation are
recommended until fever and local inflammation have subsided.

Alternative Regimen -
     Ofloxacin 300 mg orally 2 times a day for 10 days.

NOTE: Ofloxacin is contraindicated for persons less than or
equal to 17 years of age.

Follow-Up
     
     Failure to improve within 3 days requires re-evaluation of
both the diagnosis and therapy, and consideration of
hospitalization. Swelling and tenderness that persist after
completing antimicrobial therapy should be evaluated for testicular
cancer and tuberculous or fungal epididymitis.

Management of Sex Partners
     
     Patients with 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 30 days of onset of symptoms.

     Patients should be instructed to avoid sexual intercourse
until patient and partner(s) are cured. In the absence of
microbiologic test-of-cure, this means until therapy is completed
and patient and partner(s) are without symptoms.

Special Considerations

HIV Infection -
     Persons with HIV infection and uncomplicated epididymitis
should receive the same treatment as persons without HIV. Fungal
and mycobacterial causes of epididymitis are more common, however,
among patients who are immunocompromised.

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