Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Levels of evidence (Ia-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Diagnosis
It is imperative for the physician to differentiate between epididymitis and spermatic cord torsion as soon as possible using all available information, including the age of the patient, history of urethritis, clinical evaluation and Doppler (duplex) scanning of testicular blood flow.
Treatment
Only a few studies have been performed measuring the penetration of antimicrobial agents into epididymis and testis in humans. Of these, the fluoroquinolones have shown favourable properties (Ludwig et al., 1997) (IIa).
Antimicrobials should be selected on the empirical basis that in young, sexually active men Chlamydia trachomatis is usually causative, and that in older men with benign prostatic hyperplasia (BPH) or other micturition disturbances, the most common uropathogens are involved. Studies comparing microbiological results from puncture of the epididymis and from urethral swabs as well as urine have shown very good correlation. Therefore, prior to antimicrobial therapy, a urethral swab and midstream specimen of urine (MSU) should be obtained for microbiological investigation (C).
Again, fluoroquinolones, preferably those with activity against C. trachomatis (e.g., ofloxacin and levofloxacin), should be the drugs of first choice, because of their broad antibacterial spectra and their favourable penetration into the tissues of the urogenital tract. If C. trachomatis has been detected as an aetiological agent, treatment could also be continued with doxycycline, 200 mg/day, for a total treatment period of at least 2 weeks. Macrolides may be used as alternative agents (C).
Supportive therapy includes bed rest, uppositioning of the testes and antiphlogistic therapy. Since, for young men, epididymitis can lead to permanent occlusion of the epididymal ducts and thus to infertility, one should consider antiphlogistic therapy with methylprednisolone, 40 mg/day, and reduce the dose by half every second day (C).
In case of C. trachomatis epididymitis, the sexual partner should also be treated (C). If uropathogens are found as causative agents, a thorough search for micturition disturbances should be carried out to prevent relapse (C). Abscess-forming epididymitis or orchitis also needs surgical treatment. Chronic epididymitis can sometimes be the first clinical manifestation of urogenital tuberculosis.
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomized trials
Ib Evidence obtained from at least one randomized trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
IV Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
