What is the recommended treatment for epididymitis?

From the Guidelines

The recommended treatment for epididymitis depends on its cause, but typically includes antibiotics for bacterial infections, with empiric therapy indicated before culture results are available, as stated in the 2002 guidelines 1.

Treatment Approach

For sexually transmitted epididymitis in men under 35, a combination of ceftriaxone and doxycycline is often recommended, while for men over 35 or those with urinary tract infections, fluoroquinolones like levofloxacin may be prescribed.

• The treatment aims to achieve microbiologic cure of infection, improvement of signs and symptoms, prevention of transmission to others, and a decrease in potential complications such as infertility or chronic pain, as outlined in the guidelines 1.
• Pain management is essential and includes NSAIDs like ibuprofen, scrotal support, and rest.
• Ice packs can help reduce swelling, and sexual abstinence is advised until treatment is complete.

Considerations

If an abscess forms or symptoms persist despite appropriate antibiotics, urological consultation may be necessary.

• Treatment should begin promptly as delayed therapy can lead to complications including chronic pain, infertility, or abscess formation, as highlighted in the 2002 guidelines 1.
• Symptoms typically improve within 48-72 hours of starting antibiotics, but the full course must be completed even if symptoms resolve earlier.

Diagnosis and Evaluation

The evaluation of men for epididymitis should include procedures to rule out other conditions such as testicular torsion, which is a surgical emergency, as noted in the 2002 guidelines 1 and the 1998 guidelines 1.

• Testing for chlamydia and gonorrhea is strongly recommended due to the increased utility and availability of highly sensitive and specific testing methods, as stated in the 2002 guidelines 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 treatment for epididymitis caused by N. gonorrhoeae or C. trachomatis is doxycycline (PO) 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

Treatment of Epididymitis

The recommended treatment for epididymitis varies based on the patient's age and the likely causative organisms.

• For sexually active males aged 14 to 35 years, the most common pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis, and the treatment of choice is a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline 3.
• In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen 3.
• In men older than 35 years, epididymitis is usually caused by enteric bacteria, and levofloxacin or ofloxacin alone is sufficient to treat these infections 3.
• A study in 2004 found that quinolones, principally ciprofloxacin, are the most commonly prescribed first-line antibiotic for acute epididymitis, but noted that ciprofloxacin is not the optimal antimicrobial for the treatment of urogenital chlamydial infection 4.
• Another study in 1993 recommended the performance of a Gram stain on endourethral specimens from patients with acute epididymitis, and treatment with antimicrobial agents to cover both penicillinase-producing N gonorrhoeae strains and C trachomatis if inflammatory cells and Gram negative diplococci are detected 5.
• For boys with acute epididymitis who have no urinary abnormalities, antibiotics are not indicated, as the condition is self-limiting and does not lead to testicular atrophy 6.

Antibiotic Treatment

Antibiotic treatment is crucial in the management of epididymitis, especially in cases where a bacterial infection is suspected.

• The choice of antibiotic depends on the suspected causative organism and the patient's age 3, 5.
• Doxycycline and ceftriaxone are commonly used antibiotics for the treatment of epididymitis 3, 5.
• Levofloxacin and ofloxacin are also used, especially in men older than 35 years or in cases where an enteric organism is suspected 3.

Supportive Therapy

Supportive therapy, such as minimizing physical activity and prescribing analgesics, may be sufficient for boys with acute epididymitis who have no urinary abnormalities 6.

• This approach is based on the fact that the condition is self-limiting and does not lead to testicular atrophy in the absence of bacterial infection 6.