From the Guidelines
Epididymitis should be treated with empiric antibiotics, such as doxycycline 100mg twice daily and ceftriaxone 250mg as a single intramuscular injection, before culture results are available, to achieve microbiologic cure, improve signs and symptoms, prevent transmission, and decrease potential complications. The treatment approach for epididymitis involves identifying the underlying cause, which can be either sexually transmitted or non-sexually transmitted. According to the most recent guidelines, the European Association of Urology guidelines on urological infections, published in 2024 1, provide a diagnostic and treatment algorithm for men with acute epididymitis, emphasizing the importance of appropriate diagnostics to identify the predominant pathogens, which include Enterobacterales, C. trachomatis, and Neisseria gonorrhoeae.
Key considerations in the management of epididymitis include:
- Pain management with NSAIDs, such as ibuprofen 400-600mg three times daily
- Scrotal support and rest
- Ice packs to reduce swelling and discomfort
- Abstinence from sexual activity until treatment is complete and symptoms resolve
- Medical reevaluation if symptoms worsen or do not improve within 3 days of starting antibiotics to rule out other conditions like testicular torsion.
The previous guidelines from the Centers for Disease Control and Prevention, published in 2002 1 and 1998 1, also support empiric therapy for epididymitis caused by C. trachomatis or N. gonorrhoeae, but the most recent and highest quality study, published in 2024 1, should be prioritized for guiding treatment decisions.
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 epididymitis is 100 mg, by mouth, twice a day for at least 10 days 2.
- The dosage is the same for epididymitis caused by N. gonorrhoeae or C. trachomatis.
- The treatment should be continued for at least 10 days.
From the Research
Causes of Epididymitis
- The etiology of epididymitis is largely unknown, but reflux of urine into the ejaculatory ducts is considered the most common cause in children younger than 14 years 3
- In sexually active males 14 to 35 years of age, Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens 3
- In men who practice insertive anal intercourse, an enteric organism is also likely 3
- In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 3
Symptoms of Epididymitis
- Epididymitis presents as the gradual onset of posterior scrotal pain that may be accompanied by urinary symptoms such as dysuria and urinary frequency 3
- Physical findings include a swollen and tender epididymis with the testis in an anatomically normal position 3
Treatment of Epididymitis
- A single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice for sexually active males 14 to 35 years of age 3
- Ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen for men who practice insertive anal intercourse 3
- Levofloxacin or ofloxacin alone is sufficient to treat epididymitis in men older than 35 years 3
- Quinolones, such as ciprofloxacin, are commonly prescribed as first-line antibiotics, but may not be the optimal choice for treating urogenital chlamydial infection 4
- Ciprofloxacin 500 mg orally twice daily is more effective than pivampicillin 700 mg orally twice daily in treating acute epididymitis in men above the age of 40 years 5
Antibiotic Use in Pediatric Patients
- A literature review of retrospective studies found that only 16.9% of pediatric patients with acute epididymitis had a positive urinalysis, and 14.9% had a positive urine culture 6
- Despite this, 85% of pediatric patients with acute epididymitis received antibiotics, suggesting that antibiotics may be overprescribed in this population 6
- Practitioners should consider only prescribing antibiotics to patients with acute epididymitis if there is an abnormal urinalysis or urine culture 6