From the Guidelines
Management of epididymorchitis requires prompt antibiotic therapy and supportive measures, with the most recent guidelines from the European Association of Urology in 2024 recommending a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacterales 1. The treatment approach should be based on the patient's age, symptoms, and suspected cause of the infection.
- For suspected bacterial epididymorchitis, the European Association of Urology guidelines suggest the use of ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis 1.
- Supportive care includes bed rest, scrotal elevation with a folded towel or athletic supporter, ice packs for the first 24-48 hours, and pain management with NSAIDs like ibuprofen 600mg every 6 hours or narcotic analgesics if needed.
- Patients should abstain from sexual activity until treatment is complete and partners should be treated if a sexually transmitted infection is confirmed.
- Follow-up evaluation is recommended in 48-72 hours to ensure improvement, and if symptoms worsen or abscess formation is suspected, urological consultation may be necessary 1. The comprehensive approach addresses both the infectious cause and symptomatic relief, preventing complications like abscess formation or chronic pain, and is in line with the recommendations from the Centers for Disease Control and Prevention 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 management of epididymorchitis caused by N. gonorrhoeae or C. trachomatis with doxycycline is 100 mg, by mouth, twice a day for at least 10 days 2.
- The dosage is the same for both N. gonorrhoeae and C. trachomatis infections.
- The treatment should be continued for at least 10 days.
From the Research
Diagnosis and Treatment
- The management of epididymorchitis typically involves empirical treatment with antibiotics, as the condition is often caused by bacterial infections 3, 4, 5, 6.
- The choice of antibiotic depends on the suspected causative organism, with ceftriaxone and doxycycline recommended for sexually acquired epididymo-orchitis 3, 4, 6.
- In cases where enteric pathogens are suspected, ofloxacin or levofloxacin may be recommended 3, 4, 6.
- Patients with severe pain or systemic illness may require referral for analgesia, IV antibiotics, and hydration 5.
Classification and Staging
- A classification system for acute epididymo-orchitis has been developed, dividing the condition into three stages based on examination results and clinical outcomes 7.
- The classification system recommends an approach to treatment, with conservative treatment effective in some cases, while others may require surgery 7.
Patient Assessment
- Patients with epididymo-orchitis typically present with testicular pain and swelling, and may have symptoms of lower urinary tract infection, such as fever and dysuria 3, 4, 5.
- Physical examination may reveal a swollen and tender epididymis or testis, with the testis in an anatomically normal position 3, 4, 5.
- Laboratory studies, including urethral Gram stain, urinalysis, and culture, may help guide therapy 3.
Special Considerations
- Acute testicular torsion is an important differential diagnosis of acute testicular pain, and requires immediate referral to secondary care for surgical intervention 5.
- Patients with suspected epididymo-orchitis should be examined for signs of bladder outflow obstruction, such as a palpable bladder, and digital rectal exam should be performed to check for benign prostatic hyperplasia, prostate cancer, constipation, and prostatitis 5.