Urological Emergencies in Clinical Practice стр.41

Treatment of Epididymitis

Culture the urine, any urethral discharge, and blood (if system-ically unwell). Treatment consists of bed rest, analgesia, and antibiotics. Where C. trachomatis is a possible infecting organism, prescribe a 10- to 14-day course of tetracycline 500 mg four times a day or doxycycline 100 mg twice daily. If gonorrhoea is confirmed on a Gram stain of the urethral discharge (if present) and on culture, prescribe ciprofloxacin (though check the sensitivity on culture). For non-sexually transmitted disease (STD)-related epididymitis, prescribe antibiotics empirically (until culture results are available) according to your local microbiology department's advice, which will be based on local patterns of organisms isolated from urine cultures and on local patterns of antibiotic resistance. Our empirical antibiotic regimen is ciprofloxacin for 2 weeks where there is no systemic upset. When the patient is systemically unwell, we admit them for

4. OTHER INFECTIVE UROLOGICAL EMERGENCIES 53

intravenous cefuroxime 1.5 g t.i.d. and intravenous gentamicin 5 mg/kg, until they are apyrexial, at which time we switch to oral ciprofloxacin for 2 weeks.

Complications of Epididymitis

These include abscess formation, infarction of the testis, chronic pain, and infertility.

PERIURETHRAL ABSCESS

This can occur in patients with urethral stricture disease, in association with gonococcal urethritis and following urethral catheterisation. These conditions predispose to bacteria (gramnegative rods, enterococci, anaerobes, gonococcus) gaining access through Buck's fascia to the periurethral tissues. If not rapidly diagnosed and treated, infection can spread to the perineum, buttocks, and abdominal wall.

The majority (90%) of patients present with scrotal swelling and a fever. Approximately 20% will have presented with urinary retention, 10% with a urethral discharge, and 10% having spon-taneoulsy discharged the abscess through the urethra.

The abscess should be incised and drained, a suprapubic catheter placed to divert the urine away from the urethra, and broad-spectrum antibiotics commenced (gentamicin and cefuroxime) until antibiotic sensitivities are known.


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