A. Causative Agents

1. Acute in men <35 years old: usually C. trachomatis more than N. gonorrhoea
2. Older men: enteric gram negative rods, Pseudomonas, or mixed infections
3. Chronic: consider anaerobic / mixed and fungal superinfection
4. Instrumentation: mixed infection, enteric G- organisms

B. Presentation

1. Pain and swelling in scrotal area
2. Very sensitive to touch
3. Erythema quite marked
4. Fever and leukocytosis may be present

C. Diagnosis and Treatment

1. Culture of urethral swab and/or urine (immediate urinalysis with Gram Stain)
2. Complete blood count (CBC) ± blood cultures in ill patients
3. Begin therapy prior to culture results based on likely causes
4. Consider evaluation for other sexually transmitted diseases (eg. HIV, syphilis)
5. Younger men
   1. Standard chlamydia therapy - azithromycin, doxycycline
   2. Unknown organism - ofloxacin 400mg po bid x 10 days [2]
   3. Ceftriaxone 250mg im/iv x 1 + doxycycline
   4. Alternatives: TMP/SMX (Bactrim®) or Ciprofloxacin or Ofloxacin
6. Treatment of Older Men (or post-instrumentation)
   1. Concern for coexisting Prostatitis and/or orchitis
   2. Culture results are critical to use appropriate antibiotics
   3. Ofloxacin 400mg po bid until culture results available is recommended [2]

References

1. Junnila J and Lassen P. 1998. Am Fam Physician. 57(4):685
2. Ofloxacin. 1995. Med Let. 37(964):117