From the Guidelines
The recommended treatment for epididymitis is a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacterales, with consideration of parenteral therapy if severe infection is present, as outlined in the 2024 European Association of Urology guidelines 1.
Treatment Approach
The treatment approach for epididymitis depends on the suspected cause, with gonorrhoea unlikely or likely being key factors in determining the treatment regimen.
- For cases where gonorrhoea is unlikely, midstream urine for culture and urethral swab/smear are recommended, along with a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacterales 1.
- In cases where gonorrhoea is likely, ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis is recommended 1.
Supportive Measures
Supportive measures are equally important and include:
- Bed rest
- Scrotal elevation with a folded towel
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen 400-600mg three times daily for pain and inflammation
- Ice packs to reduce swelling
Follow-up Evaluation
If symptoms worsen or don't improve within 72 hours of treatment, follow-up evaluation is necessary to rule out abscess formation or alternative diagnoses 1.
Viral Epididymitis
Viral epididymitis is managed with supportive care only, as antibiotics are ineffective against viruses. Treatment should begin promptly to prevent complications like abscess formation or chronic epididymitis.
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
Epididymitis Treatment
The recommended treatment for epididymitis varies based on the patient's age and the likely causative organisms 3.
- For sexually active males aged 14 to 35 years, the most common pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis. The treatment of choice in this age group 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 transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction; levofloxacin or ofloxacin alone is sufficient to treat these infections 3.
- Alternative treatments for Chlamydia trachomatis infection include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days 4.
- A study comparing the efficacy of azithromycin and ceftriaxone for the treatment of uncomplicated gonorrhea found that both treatments were effective, but azithromycin was associated with a higher frequency of gastrointestinal side effects 5.
- Another study found that a single 1-g intravenous dose of ceftriaxone plus doxycycline was superior to a single 800-mg oral dose of cefixime plus doxycycline for the treatment of Chlamydia trachomatis and Neisseria gonorrhoeae co-infection 6.
- Trovafloxacin has also been shown to be effective in the treatment of uncomplicated chlamydial infection, with eradication rates equivalent to those of doxycycline in women, but not in men 7.