Treatment for Epididymitis Not Due to STI
For epididymitis most likely caused by enteric organisms (non-STI), ofloxacin 300 mg orally twice a day for 10 days or levofloxacin 500 mg orally once daily for 10 days is the recommended treatment. 1
Etiology and Diagnosis
Epididymitis not due to STI is typically caused by:
- Gram-negative enteric organisms (most commonly E. coli)
- More frequent in men >35 years of age
- Associated with urinary tract infections, recent urinary tract instrumentation/surgery, or anatomical abnormalities 1
Diagnostic evaluation should include:
- Urinalysis and urine culture to identify causative organisms
- Culture and Gram-stained smear of uncentrifuged urine for Gram-negative bacteria
- Examination of first-void urine for leukocytes if urethral Gram stain is negative 1
Treatment Algorithm
1. For men >35 years or with risk factors for enteric infection:
- First-line therapy: Ofloxacin 300 mg orally twice a day for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 1
- These fluoroquinolones provide excellent coverage against common enteric pathogens
2. Supportive measures (essential adjuncts):
- Bed rest
- Scrotal elevation
- Analgesics
- Continue until fever and local inflammation have subsided 1
3. Follow-up:
- Reevaluation if no improvement within 3 days
- Consider alternative diagnoses if swelling and tenderness persist after completing antibiotics 1
Special Considerations
Differential Diagnosis
If symptoms persist after treatment, consider:
- Testicular tumor
- Abscess
- Infarction
- Testicular cancer
- Tuberculous or fungal epididymitis 1
Pediatric Cases
In prepubertal boys, epididymitis is often idiopathic rather than bacterial:
- Antibiotics may not be indicated if urinalysis is normal 2, 3
- Supportive therapy alone may be sufficient in children without pyuria 2
Immunocompromised Patients
- Patients with HIV infection who have uncomplicated epididymitis should receive the same treatment as those without HIV
- Consider fungal and mycobacterial causes in immunocompromised patients 1
Common Pitfalls
Misdiagnosis: Failing to distinguish between STI and non-STI causes based on age and risk factors
- Always consider testicular torsion in cases of acute scrotal pain, especially with sudden onset 1
Inappropriate antibiotic selection: Using antibiotics targeted at STI pathogens when enteric organisms are more likely
Inadequate follow-up: Not reassessing patients who fail to improve
- Treatment failure within 3 days requires reevaluation of both diagnosis and therapy 1
Overlooking serious conditions: Missing testicular torsion, which is a surgical emergency
- Emergency evaluation is needed for sudden onset, severe pain, or when test results don't support infection 1
By following this evidence-based approach to non-STI epididymitis, clinicians can effectively manage this condition while minimizing complications such as chronic pain and infertility.