From the Guidelines
Management of epididymorchitis should prioritize empiric antibiotic therapy to cover the most likely causes, including Chlamydia trachomatis and Neisseria gonorrhoeae, to achieve microbiologic cure, improve symptoms, prevent transmission, and decrease potential complications. The choice of antibiotic regimen depends on the patient's age, sexual history, and presence of urinary tract abnormalities. For sexually transmitted infections in men under 35, treatment with ceftriaxone 500mg IM once plus doxycycline 100mg twice daily for 10 days is recommended 1. Key aspects of management include:
- Antibiotic therapy based on the likely cause
- Pain management with NSAIDs like ibuprofen 400-600mg every 6-8 hours
- Scrotal support and elevation to reduce inflammation
- Bed rest until fever and local inflammation have subsided, as recommended as an adjunct to therapy 1
- Abstinence from sexual activity until treatment completion and treatment of partners if STI-related
- Adequate hydration Follow-up is essential to ensure resolution, and surgical intervention may be necessary if symptoms worsen or abscess formation occurs. In cases where the cause is not sexually transmitted, such as in older men or those with urinary tract abnormalities, alternative antibiotic regimens like levofloxacin 500mg daily or ciprofloxacin 500mg twice daily for 10-14 days may be considered.
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 of Epididymorchitis
- The diagnosis of epididymorchitis is typically based on a combination of clinical presentation, physical examination, and laboratory tests 3, 4, 5.
- Patients with epididymorchitis typically present with a gradual onset of scrotal pain and symptoms of lower urinary tract infection, including fever 3, 4.
- Physical findings include a swollen, tender epididymis or testis located in the normal anatomic position with an intact ipsilateral cremasteric reflex 3, 4.
Causes of Epididymorchitis
- The causes of epididymorchitis vary depending on the age group, with Chlamydia trachomatis and Neisseria gonorrhoeae being the most common pathogens in men under 35 years of age 3, 4, 5.
- In men over 35 years of age, coliform bacteria are the primary pathogens 3, 4, 5.
- Other causes of epididymorchitis include enteric organisms, particularly in men who practice insertive anal intercourse 5.
Treatment of Epididymorchitis
- The treatment of epididymorchitis is based on the likely causative organisms and patient age 3, 4, 5.
- For men under 35 years of age, a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice 3, 5.
- For men over 35 years of age, levofloxacin or ofloxacin alone is sufficient to treat epididymorchitis caused by enteric bacteria 3, 5.
- Recent guidelines suggest that selection of fluoroquinolone antibiotics with anti-Chlamydial activity may be more appropriate in the management of sexually active men in the over 35 years age group 6.