From the Guidelines
Epididymitis should be treated with a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacterales, with consideration of parenteral therapy if the infection is severe. The treatment approach for epididymitis is guided by the European Association of Urology guidelines on urological infections, which were updated in 2024 1. According to these guidelines, the diagnosis and treatment of epididymitis involve a clinical assessment, midstream urine for culture, urethral swab/smear, and scrotal ultrasound examination.
For patients with suspected epididymitis, the guidelines recommend a course of antibiotics active against Chlamydia trachomatis and Enterobacterales, with options including ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis 1. It is essential to consider the severity of the infection and the potential need for parenteral therapy.
Key considerations in the treatment of epididymitis include:
- Clinical assessment to determine the severity of the infection
- Laboratory tests, such as midstream urine for culture and urethral swab/smear, to guide antibiotic selection
- Scrotal ultrasound examination to evaluate for complications like abscess formation
- Antibiotic therapy with a single agent or a combination of two agents active against Chlamydia trachomatis and Enterobacterales
- Consideration of parenteral therapy for severe infections
- Follow-up to monitor response to treatment and adjust the treatment plan as needed 1.
In terms of specific antibiotic regimens, the guidelines suggest ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis, which may include doxycycline or azithromycin 1. The choice of antibiotic and the duration of treatment should be guided by the clinical assessment, laboratory results, and the severity of the infection.
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 treatment for epididymitis (inflammation of the epididymis) is doxycycline 100 mg, by mouth, twice a day for at least 10 days for cases caused by N. gonorrhoeae or C. trachomatis 2.
From the Research
Treatment of Epididymitis
The treatment of epididymitis varies based on the patient's age and the likely causative organisms.
- For sexually active males between 14 and 35 years of age, 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, 4.
- 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, 5.
- Supportive measures and antimicrobial agents are the mainstay of therapy for acute epididymitis 6.
- Initial outpatient therapy is empirical and targets the most common pathogens, with ceftriaxone and doxycycline recommended when Chlamydia trachomatis and Neisseria gonorrhoeae are suspected, and ofloxacin or levofloxacin recommended when coliform bacteria are suspected 4.
Special Considerations
- In cases where fluoroquinolones are not effective due to rising resistance, alternative antimicrobials with adequate penetration into genital tissues may be necessary 5.
- Men with symptoms of "prostatitis" must be evaluated using both urine and prostatic secretions to document infection and inflammation, and men with documented chronic bacterial prostatitis require long courses of antimicrobials to effect cure 7.