From the Guidelines
Orchiepididymitis requires prompt treatment with antibiotics, and the choice of antibiotic depends on whether the cause is sexually transmitted or not, with ceftriaxone and doxycycline being the standard regimen for sexually transmitted cases, as recommended by the most recent guidelines 1. The treatment of orchiepididymitis should prioritize the prevention of complications such as infertility, chronic pain, and transmission to others, as highlighted in the 1998 guidelines for treatment of sexually transmitted diseases 1. Some key points to consider in the management of orchiepididymitis include:
- The use of antibiotics, such as ceftriaxone 250mg as a single intramuscular injection plus doxycycline 100mg twice daily for 10 days, for sexually transmitted causes, as recommended by the guidelines 1
- The use of fluoroquinolones, such as levofloxacin 500mg daily for 10 days, for non-sexually transmitted cases
- Pain management with NSAIDs, such as ibuprofen 400-600mg three times daily, scrotal support, and rest
- The application of ice packs intermittently to reduce swelling
- The importance of abstaining from sexual activity until treatment is complete and ensuring that partners are treated if the cause is sexually transmitted
- The need for medical reevaluation if symptoms worsen or do not improve within 72 hours to rule out complications such as abscess formation or testicular torsion, which would require surgical intervention, as highlighted in the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain 1. It is also important to consider the role of imaging, such as ultrasound, in the diagnosis and management of orchiepididymitis, as discussed in the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain 1. Ultimately, the goal of treatment is to prevent morbidity, mortality, and improve quality of life, and the choice of treatment should be guided by the most recent and highest quality evidence, such as the 2024 update of the ACR Appropriateness Criteria for acute onset of scrotal pain 1.
From the FDA Drug Label
Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days
The recommended dose of doxycycline for acute epididymo-orchitis (also known as orquiepididimitis) is 100 mg, by mouth, twice a day for at least 10 days. This applies to cases caused by either N. gonorrhoeae or C. trachomatis 2.
From the Research
Definition and Causes of Epididymo-Orchitis
- Epididymo-orchitis (EO) is an inflammation of the epididymis and testis, which can be acute, sub-acute, or chronic 3.
- The most common causes of EO are sexually transmitted infections (STIs) in younger men and urinary tract pathogens in older men 3, 4.
- The most common pathogens in men under 35 are N gonorrhoeae and C trachomatis, while E coli is the most common cause of acute epididymitis in men over 35 3.
Symptoms and Diagnosis
- EO typically presents with testicular pain and swelling, and examination may reveal a swollen, tender testis with swelling of the epididymis 3.
- Acute testicular torsion is an important differential diagnosis of acute testicular pain, especially in younger men, and requires immediate referral to secondary care 3.
- Diagnostic tests and empirical treatment should be started in patients with objective swelling and tenderness on testicular examination 4.
Treatment and Management
- Empirical treatment for sexually acquired EO has changed to ceftriaxone 1g intramuscularly and doxycycline 4.
- Ofloxacin or doxycycline is recommended in patients with EO probably due to non-gonococcal organisms 4.
- A clinical care pathway has been produced to simplify the management of EO, and a patient information leaflet has been developed 4.
- Patients with indwelling urethral catheters are at high risk of multiple drug resistance and should be treated empirically with both a fluoroquinolone and a third-generation cephalosporin until antimicrobial susceptibility testing has been completed 5.
Complications and Prognosis
- Serious complications of EO can include abscess formation, testicular infarction, and infertility 6.
- About 40 out of 100 patients develop post-inflammatory sub-fertility, and virulence factors like haemolysin A produced by uropathogenic E. coli can have a negative impact on semen parameters 5.
- With adequate antibiotic treatment, there is no evidence for testicular atrophy, and only one out of 10 men relapses 5.