- Patients given advice on duration of symptoms, potential causes of epididymo-orchitis, and possible long term consequences for themselves and their partners. This can be reinforced by giving them a patient information leaflet.
- Patients should be advised to abstain from sexual intercourse until they and their partner have completed treatment and follow up in those with confirmed and suspected STI.
- All patients with probable STI should be advised to attend a sexual health clinic for STI testing. When antimicrobials are commenced in the non sexual health setting, a first void urine for C. trachomatis and N. gonorrhoeae NAAT testing, urethral swab for N. gonorrhoeae culture and MSU for culture should be taken.
- Rest, analgesia and scrotal support.
- An ultrasound of the testes if there is uncertainty about the clinical diagnosis or need to exclude associated complications
Management, treatment and follow-up
Warning
Empirical treatment for epididymo-orchitis should be started in patients with objective swelling and tenderness on testicular examination.
Empirical treatment should be given to all patients with epididymo-orchitis at the time of the visit before culture/ NAAT results are available.
The antibiotic regimen chosen should be determined in light of the immediate tests. Age, history of insertive anal intercourse, recent prostrate biopsy, vasectomy, urinary tract instrumentation, or catheterisation or any known urinary tract abnormalities in the patient should be considered.
1. For epididymo-orchitis most probably due to any sexually transmitted pathogen, e.g;
- younger patient
- high risk sexual history - a new sexual partner or more than one sexual partner in last 12 months
- contact of an STI
- no previous UTI
- urethral discharge present
- urine diplstick positive for leucocytes only.
a. Most probably due to any STI:
Ceftriaxone 1g IM single dose
PLUS
Doxycycline 100mg orally twice daily 14 days
b. Most probably due to Chlamydia or other non-gonococcal sexually transmitted pathogen (e.g., where gonorrhoea has been ruled out by gram stain and no risk factors for gonorrhoea identified) could consider:
First line: Doxycycline 100mg orally twice daily 14 days
Second Line Ofloxacin 200mg orally twice daily 14 days
(see below for MHRA recommendations on the the use of ofloxacin and other fluoroquinolones)
2. For epididymo-orchitis likely caused by sexually transmitted infections and enteric organisms consider, e.g., STI risk factors in men who practice insertive anal sex:
Ceftriaxone 1g IM single dose
PLUS
Ofloxacin* 200mg orally twice daily 14 days
(see below for MHRA recommendations on the the use of ofloxacin and other fluoroquinolones)
3. Epididymo-orchitis most probably due to an enteric pathogen, e.g;
- older patient
- low risk sexual history
- previous urological procedures or urinary tract infections
- men who engage in insertive anal sex
- men with known abnormalities of the urinary tract
- no urethral discharge
- positive urine dipstick for leucocytes and nitrites
Ofloxacin* 200mg orally twice daily 14 days
OR
Levofloxacin* 500mg once daily for 10 days
(see below for MHRA recommendations on the the use of ofloxacin, levofloxacin and other fluoroquinolones)
OR
Amoxicillin/clavulanate 625mg orally three times daily for 10 days when quinolones contraindicated
4. Where mycoplasma genitalium is identified treatment should guided to include an appropriate antibiotic, for example:
Moxifloxacin* 400mg once daily for 14 days
(see below for MHRA recommendations on the the use of moxifloxacin and other fluoroquinolones)
In those with severe epididymo-orchitis or features suggestive of bacteraemia, inpatient management is required. Refer to BASHH for advice re antibiotic therapy.
If any of the recommended regimens are contraindicated – seek advice from senior colleague.
If there is no improvement in the patient’s condition by 72hrs, the diagnosis should be reassessed and therapy re-evaluated.
* MHRA recommendations on the the use of fluoroquinolones
Fluoroquinolones must only be prescribed when other commonly recommended antibiotics are inappropriate.
Refer to the full MHRA statement at https://www.gov.uk/government/news/mhra-introduces-new-restrictions-for-fluoroquinolone-antibiotics
Advice for healthcare professionals:
Fluoroquinolones can cause long-lasting (up to months or years), disabling and potentially irreversible side effects, sometimes affecting multiple body systems and senses.
Patients should be advised to stop fluoroquinolone treatment at the first signs of a serious adverse reaction such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy and central nervous system effects, and to contact their doctor immediately.
Clinician should also
- Be alert to the risk of suicidal thoughts and behaviours with use of fluoroquinolone antibiotics.
- Avoid fluoroquinolone use in patients who have previously had serious adverse reactions with a quinolone antibiotic (for example, nalidixic acid) or a fluoroquinolone antibiotic
- Prescribe fluoroquinolones with special caution for people older than 60 years and for those with renal impairment or solid-organ transplants, because they are at a higher risk of tendon injury
- Avoid coadministration of a corticosteroid with a fluoroquinolone since this could exacerbate fluoroquinolone-induced tendinitis and tendon rupture
BASHH advises that fluoroquinolones are prescribed only when judged to be the most appropriate treatment for the patient’s infection after considering factors such as likely causative organisms, antimicrobial resistance factors, the availability of alternative agents, and pharmacological considerations such as tissue penetration. www.bashh.org/resources/93/aemhra_statement
Advice for healthcare professionals to give to patients and caregivers:
Fluoroquinolone antibiotics have been reported to cause serious side effects involving tendons, muscles, joints, nerves, or mental health – in some patients, these side effects have caused long-lasting or permanent disability.
Stop taking your fluoroquinolone antibiotic and contact your doctor immediately if you have any of the following signs of a side effect:
- tendon pain or swelling – if this happens, rest the painful area until you can see your doctor
- pain in your joints or swelling in joints such as in the shoulders, arms, or legs
- abnormal pain or sensations (such as persistent pins and needles, tingling, tickling, numbness, or burning), weakness in the legs or arms, or difficulty walking
- severe tiredness, depressed mood, anxiety, problems with your memory or severe problems sleeping
- changes in your vision, taste, smell or hearing
Tell your doctor if you have had any of the above effects at any point while taking a fluoroquinolone – this means you should avoid them again in the future. An information sheet is available for patients in regular print or large print.
Further follow up whether in person or by telephone is recommended at two weeks to:
- Assess compliance with treatment.
- Ensure completion with partner notification.
- Check for improvement of symptoms.
- If patients tested positive for N.gonorrhoea, arrange test of cure 2 to 3 weeks using NAAT after completion of antimicrobial therapy.
- Test for HIV and syphilis at the end of relevant window period(s) from the contact of concern if indicated by sexual history.
- For patients with persisting symptoms arrangements made for clinical review. Swelling and tenderness can persist after microbiological therapy is complete but should have significantly improved. Where there is little improvement, further investigations such as an ultrasound scan or urological assessment should be considered. Differential diagnosis to consider in these circumstances are:
- testicular tumour/ abscess/ infarction/ ischemia/ alternative infections such as TB and mumps, or rarer non-infective causes.
- Uropathogen confirmed epidiymo-orchitis is an indication for urology referral to exclude structural abnormalities/urinary tract obstruction.
- All patients with likely sexually acquired epididymo-orchitis should be referred to an individual trained in partner notification.
- Sexual partners potentially at risk should be tested for STIs and consideration given to provide treatment to cover C.trachomatis and N.gonorrhoeae if confirmed in the index patient.
- The look back period is arbitrary. Four weeks is suggested on the basis of the current chlamydia guidelines, and 2 weeks (or their last partner if longer) for gonorrhoea.