Review Question - QID 216595

This patient is presenting with tenderness over the superior pole of his testicle with increased blood flow on ultrasound, which is concerning for epididymitis. Given this patient engages in penetrative intercourse with both men and women (implying penetrative anal intercourse), the optimal treatment regimen for him is ceftriaxone and ofloxacin.

Epididymitis presents with dull, unilateral testicular pain with a swollen, tender, and erythematous scrotum. Classically, Prehn sign is present, which describes pain relief with elevation of the testicle (though this is neither sensitive nor specific). The diagnosis can be suppored with an ultrasound which will show increased blood flow to the affected testicle. Treatment is based on the epidemiology and sexual practices of the patient. In patients who engage in penetrative anal intercourse, treatment for Escherichia coli, other coliforms, Pseudomonas aeruginosa, Neisseria gonorrhoeae, and Chlamydia trachomatis is needed. The preferred treatment regimen for this patient population is ceftriaxone and a fluoroquinolone (e.g., ofloxacin).

McConaghy and Panchal note the treatment regimens in different patient populations with epididymitis. They also note the complications of infertility and chronic pain if untreated. They recommend early treatment to avoid these complications.

Incorrect Answers:
Answer 1: Ceftriaxone and azithromycin is an appropriate treatment regimen for cervicitis in pregnancy. Cervicitis presents with vaginal/cervical discharge and cervical motion tenderness. The diagnosis can be made clinically and supported with PCR. Note that doxycycline is avoided in pregnancy.

Answer 2: Ceftriaxone and doxycycline are the appropriate antibiotics for epididymitis when it is sexually transmitted in patients < 35 years of age or those with high-risk sexual behaviors. It does not cover enteric organisms as should be covered in the setting of penetrative anal intercourse.

Answer 4: Ceftriaxone, doxycycline, and ofloxacin is not a viable regimen for epididymitis and is too broad. Excess use of antibiotics can lead to antibiotic resistance, diarrhea, and infection with Clostridioides difficile.

Answer 5: Ofloxacin is appropriate management of non-sexually transmitted epididymitis in patients <35 years of age without high-risk sexual behaviors.

Bullet Summary:
Patients with epididymitis in the setting of penetrative anal intercourse should be treated with ceftriaxone and a fluoroquinolone.