What is the best treatment for epididymitis in a non-sexually active adult male with suspected urinary tract infection?

From the Guidelines

The best treatment for epididymitis in a non-sexually active adult male with suspected urinary tract infection is a course of antibiotics targeting common urinary pathogens, and based on the latest guidelines, treatment with levofloxacin is indicated. The patient's presentation with a swollen red scrotum, dysuria, urgency, and a green, purulent urethral discharge, along with a positive Prehn’s sign and laboratory findings, is consistent with acute epididymitis, likely caused by a urinary tract infection 1. The European Association of Urology guidelines on urological infections, updated in 2024 1, recommend treating acute epididymitis with antibiotics that target the most common pathogens, including Enterobacterales. Key points to consider in the treatment include:

• The use of fluoroquinolones, such as levofloxacin, as first-line therapy due to their effectiveness against common urinary pathogens 1.
• The importance of completing a full 10-14 day course of antibiotics to prevent recurrence.
• Supportive measures, such as bed rest, scrotal elevation, and pain management with NSAIDs, to help alleviate symptoms.
• Monitoring for improvement within 48-72 hours and reevaluating if symptoms worsen or do not improve, to consider possible complications or alternative diagnoses. Given the patient's symptoms and the guidelines, treatment with levofloxacin is the most appropriate choice, as it directly addresses the likely cause of the epididymitis and is in line with current recommendations 1.

From the FDA Drug Label

Adults: The usual dose of oral doxycycline is 200 mg on the first day of treatment (administered 100 mg every 12 hours) followed by a maintenance dose of 100 mg/day 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 best treatment for epididymitis in a non-sexually active adult male with suspected urinary tract infection is Treatment with doxycycline plus ceftriaxone.

• The patient has symptoms of epididymitis, including a swollen red scrotum, dysuria, and urgency.
• The presence of a green, purulent urethral discharge and a positive Prehn’s sign suggests a possible infection with N. gonorrhoeae or C. trachomatis.
• The patient's laboratory results, including a white blood cell count of 14,000 with 10 bands and urinalysis revealing 5-10 RBCs and TNTC WBCs, support the diagnosis of an infection.
• Doxycycline is indicated for the treatment of acute epididymo-orchitis caused by N. gonorrhoeae or C. trachomatis, and ceftriaxone is often used in combination with doxycycline to cover other possible pathogens 2.

From the Research

Epididymitis Treatment

The patient's symptoms, including a swollen red scrotum, dysuria, urgency, and a green, purulent urethral discharge, are indicative of epididymitis. Given the patient's age and lack of sexual activity, the likely cause is an enteric organism, which is commonly seen in men over 35 years old 3.

Treatment Options

• The patient's presentation and laboratory results suggest a bacterial infection, and treatment should be initiated promptly to reduce morbidity.
• Treatment with levofloxacin is a suitable option for epididymitis caused by enteric organisms in men over 35 years old 3, 4.
• The use of doxycycline plus ceftriaxone is typically recommended for sexually active males with epididymitis caused by Neisseria gonorrhoeae and Chlamydia trachomatis, which is not the likely cause in this case 3.
• Testicular ultrasound may be useful in evaluating testicular torsion or other complications, but it is not the primary treatment for epididymitis.
• Testicular biopsy is not typically indicated for the treatment of epididymitis.

Recommended Treatment

Based on the patient's presentation and the likely cause of the infection, treatment with levofloxacin is the most appropriate option. This is supported by studies that recommend fluoroquinolones, such as levofloxacin, as the primary treatment for epididymitis caused by enteric organisms in men over 35 years old 3, 4.