The Prostatitis Foundation

Digital Rectal Examination (DRE) Is Contraindicated And Must Not Be Performed In The Presence Of Acute Epididymitis


From: Jordan Dimitrakov, MD
It is very important to know that digital rectal examination (DRE) [also "drainage" as the term is used on this website -- webmaster] is contraindicated and must not be performed in the presence of acute epididymitis. All urologists know that and insistence on part of the patient is not to the patient's benefit. Here are the current CDC recommendations on the diagnosis and treatment of epididymitis (if this is really what you have):
MMWR. Morbidity and Mortality Weekly Report Volume 47 Number RR-1 January 23, 2022 Copyright (c) 1998 The Centers for Disease Control and Prevention (Reprinted with permission)

1998 Guidelines for Treatment of Sexually Transmitted Diseases


Among sexually active men aged <35 years, epididymitis is most often caused by C. trachomatis or N. gonorrhoeae. Epididymitis caused by sexually transmitted E. coli infection also occurs among homosexual men who are the insertive partners during anal intercourse. Sexually transmitted epididymitis usually is accompanied by urethritis, which often is asymptomatic. Nonsexually transmitted epididymitis associated with urinary tract infections caused by Gram-negative enteric organisms occurs more frequently among men aged >35 years, men who have recently undergone urinary tract instrumentation or surgery, and men who have anatomical abnormalities. Although most patients can be treated on an outpatient basis, hospitalization should be considered when severe pain suggests other diagnoses (e.g., torsion, testicular infarction, and abscess) or when patients are febrile or might be noncompliant with an antimicrobial regimen.
Diagnostic Considerations
Men who have epididymitis typically have unilateral testicular pain and tenderness; hydrocele and palpable swelling of the epididymis usually are present. Testicular torsion, a surgical emergency, should be considered in all cases but is more frequent among adolescents. Torsion occurs more frequently in patients who do not have evidence of inflammation or infection. Emergency testing for torsion may be indicated when the onset of pain is sudden, pain is severe, or the test results available during the initial examination do not enable a diagnosis of urethritis or urinary tract infection to be made. If the diagnosis is questionable, an expert should be consulted immediately, because testicular viability may be compromised.
    The evaluation of men for epididymitis should include the following procedures:
  • A Gram-stained smear of urethral exudate or intraurethral swab specimen for diagnosis of urethritis (i.e., 5 polymorphonuclear leukocytes per oil immersion field) and for presumptive diagnosis of gonococcal infection.
  • A culture of urethral exudate or intraurethral swab specimen, or nucleic acid amplification test (either on intraurethral swab or firstvoid urine) for N. gonorrhoeae and C. trachomatis.
  • Examination of first-void urine for leukocytes if the urethral Gram stain is negative.
  • Culture and Gram-stained smear of uncentrifuged urine should be obtained.
  • Syphilis serology and HIV counseling and testing.
Empiric therapy is indicated before culture results are available. Treatment of epididymitis caused by C. trachomatis or N. gonorrhoeae will result in: a) a microbiologic cure of infection, b) improvement of the signs and symptoms, c) prevention of transmission to others, and d) a decrease in the potential complications (e.g., infertility or chronic pain).
Recommended Regimens
    For epididymitis most likely caused by gonococcal or chlamydial infection:
  • Ceftriaxone 250 mg IM in a single dose, PLUS
  • Doxycycline 100 mg orally twice a day for 10 days.
    For epididymitis most likely caused by enteric organisms, or for patients allergic to cephalosporins and/or tetracyclines:
  • Ofloxacin 300 mg orally twice a day for 10 days
  • .

As an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided.
Failure to improve within 3 days requires reevaluation of both the diagnosis and therapy. Swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively. The differential diagnosis includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis.
Management of Sex Partners
Patients who have epididymitis that is known or suspected to be caused by N. gonorrhoeae or C. trachomatis should be instructed to refer sex partners for evaluation and treatment. Sex partners of these patients should be referred if their contact with the index patient was within the 60 days preceding onset of symptoms in the patient.
Patients should be instructed to avoid sexual intercourse until they and their sex partners are cured. In the absence of a microbiologic test of cure, this means until therapy is completed and patient and partner(s) no longer have symptoms.
Special Considerations
HIV Infection
Patients who have uncomplicated epididymitis and also are infected with HIV should receive the same treatment regimen as those who are HIV-negative. Fungi and mycobacteria, however, are more likely to cause epididymitis in immunosuppressed patients than in immunocompetent patients.
Further Comments from Dr.Dimitrakov:

There was a study done back in the 1970s I think by Prof. Mardh in Sweden who found some increased incidence of epidydimitis in men undergoing rigorous prostatic massage in the presence of undiagnosed chlamydial infection. The findings of this study as far as chlamydia is concerned are doubtful since the tests used back then are now deemed to be non-specific (meaning being positive for a presumptive chlamydial infection, whereas another infection was present) but the incidence of epididymitis is a clinical finding which still has its own significance. Moreover, those were cases of full-blown epididymitis and not misdiagnosed orchalgia or ultrasound-diagnosed (ultrasound was not available then).


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