Professional Documents
Culture Documents
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MANAGEMENT OF SYNDROMES
. The presence of an observable mucopurulent/ biological results are available11. The antibiotic
purulent urethral discharge is also indicative regimen chosen should be determined in the
of urethritis2. However, this cannot reliably light of the immediate tests as well as the age
differentiate between gonococcal and NGU of the patient, the sexual history, any recent
and the absence of such a discharge does not instrumentation or catheterization and any
exclude urethritis known urinary tract abnormalities in the
. A urethral culture for N. gonorrhoeae patient
. C. trachomatis should also be sought . Bed rest, scrotal elevation and support, and
. Urinalysis of the mid-stream urine (MSU) analgesics are recommended. Non-steroidal
specimen, using a dipstick which contains anti-in ammatory drugs may be helpful 34,35
leucocyte esterase and nitrites, in addition to . If torsion is suspected an urgent urological
blood protein and glucose. These dipsticks are opinion must be sought.
an established screening test for bacterial
urinary tract infections (UTI). However, they
have not been assessed speci cally in a STD Epididymo-orchitis secondary to N. gonorrhoeae
clinic23. The presence of blood in the MSU is or NGU including C. trachomatis
usually the result of taking a urethral smear, General advice
and positive leucocyte esterase activity may
re ect urethritis and not a UTI, indeed a . See guideline on management of urethritis22.
positive leucocyte esterase test in the FPU Indications for therapy
specimen is indicative of urethritis, although
this has a poor sensitivity2,24 26). Thus the . Symptoms and signs of epididymo-orchitis
results of these for diagnosing a UTI should . Urethritis detected
be viewed with scepticism. Nevertheless, a . UTI not suspected.
positive nitrite test is very speci c although its
sensitivity is only 40 80%27 Recommended regimens
. MSU for microscopy and bacterial culture. . Doxycycline 100 mg twice daily for 14 days7,15
Consideration should be given to: . O oxacin 200 mg twice daily for 14 days 9,36,37.
. Colour Doppler ultrasound is useful to help For epididymo-orchitis where gonococcal infection
differentiate between epididymo-orchitis and is suspected, either of the following in addition to
torsion of the spermatic cord28 31. doxycycline should be given:
. Cipro oxacin 500 mg stat or ceftriaxone
Differential diagnosis 250 mg intramuscularly.
. Torsion of the testis Antibiotics used for gonorrhoea may need to be
. Epididymo-orchitis secondary to N. gonorrhoeae varied according to local knowledge of antibiotic
or NGU including C. trachomatis sensitivities. If tetracycline resistance is common
. Epididymo-orchitis secondary to enteric o oxacin may be preferable.
organisms
. Testicular or epididymal tumour.
Epididymo-orchitis secondary to enteric organism
Torsion of the spermatic cord (testicular torsion) is
the main differential diagnosis. It is a surgical General advice
emergency. It should be considered in all patients The following should be discussed and clear
and should be excluded rst as testicular salvage written information provided:
becomes decreasingly likely with time32,33. Torsion . A detailed explanation of what epididymo-
is more likely if: orchitis is and what causes it
. The onset of pain is sudden . Side-effects of treatment and importance of
. The pain is severe complying fully with it and what to do if a
. Tests performed during the initial visit show dose is missed.
neither the presence of a urethritis nor likely Indications for therapy
UTI
. The patient is younger than 20 years-of-age . symptoms and signs of epididymo-orchitis
(the peak incidence is in adolescents), but it . UTI strongly suspected.
can occur at any age32,33.
Recommended regimens
MANAGEMENT . O oxacin 200 mg twice daily for 14 days
. Trimethoprim 200 mg twice daily for 14 days
General
. Antibiotics used may need to be varied
. Empirical therapy should be given to all according to local knowledge of antibiotic
patients with epididymo-orchitis before micro- sensitivities.
part of the penis towards the meatus. This can used43. Alternatives to cipro oxacin 500 mg are
be undertaken by the patient detailed elsewhere22,39.
. The absence of urethral discharge does not Follow-up should take place after 3 days or
exclude urethritis sooner if there is no improvement. It is an essential
. In gonococcal infection the discharge is usually part of management. The differential diagnoses for
more evident and purulent than that in NGU. patients who fail to respond to therapy is as
Nevertheless, the severity of urethritis cannot detailed previously. However, resistant gonococcal
differentiate reliably between gonococcal and infection may be more common as a cause of
NGU. failure, for the reason detailed above.
Investigations References
1 Clinical Effectiveness Group. National guideline for the
Microscope present: management of epididymo-orchitis. Sex Trans Inf 1999;
75(suppl 1):S51 3
. See guideline on urethritis22
2 Centers for Disease Control and Prevention. 1998 guidelines
. Gram stain for Gram-negative diplococci to
for treatment of sexually transmitted diseases. MMWR Morb
exclude gonorrhoea. This has a sensitivity of Mortal Wkly Rep 1998;47:1 112
490% in experienced hands. 3 Van Voorst Vader PC, Van der Meijden WI, Cairo I, et al.,
eds. Sexually Transmitted Diseases: Netherlands Diagnosis and
Microscope absent: Therapy Guidelines 1997. Utrecht: Stichting SOA-bestrijding,
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4 Krieger JN. New sexually transmitted diseases treatment
ble on examination, or
guidelines. J Urol 1995;154:209 13
. Positive leucocyte esterase dipstick test on
5 Berger RE, Alexander ER, Harnisch JP, et al. Etiology,
FPU specimen, or manifestations and therapy of acute epididymitis: prospec-
. Positive two-glass urine test. The foreskin tive study of 50 patients. J Urol 1979;121:750 4
should be retracted fully and the patient asked 6 Harnish JP, Berger RE, Alexander ER, Monda GD, Holmes
to urinate into two clean specimen glasses, the KK. Aetiology of acute epididymitis. Lancet 1977;i:819 21
rst 10 20 ml into one glass, the rest into the 7 Berger RE, Alexander ER, Monda GA, Ansell J, McCormick
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