What is the initial treatment for epididymitis?

Initial Treatment for Epididymitis

For sexually active men under 35 years, the initial treatment for epididymitis is ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

Etiology and Treatment Algorithm

Treatment selection depends primarily on patient age and likely causative organisms:

1. Sexually active men <35 years:

   • Most common pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae
   • Treatment: Ceftriaxone 250 mg IM (single dose) PLUS doxycycline 100 mg orally twice daily for 10 days 1

2. Men who practice insertive anal intercourse:

   • Consider enteric organisms in addition to STIs
   • Treatment: Ceftriaxone 250 mg IM (single dose) PLUS either ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2

3. Men >35 years or with recent urinary tract instrumentation/surgery:

   • Most common pathogens: Gram-negative enteric organisms
   • Treatment: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1

Supportive Measures

In addition to antimicrobial therapy, the following adjunctive measures are recommended:

• Bed rest
• Scrotal elevation
• Analgesics
• Continue until fever and local inflammation have subsided 1

Diagnostic Considerations

Before initiating treatment, the following diagnostic steps are important:

• Rule out testicular torsion (surgical emergency) - especially in adolescents with sudden onset of severe pain 1, 3
• Obtain urethral Gram stain for evidence of urethritis
• Collect specimens for N. gonorrhoeae and C. trachomatis testing
• Examine first-void urine for leukocytes if urethral Gram stain is negative
• Consider syphilis serology and HIV testing 1

Follow-Up and Complications

• Patients should show improvement within 3 days of starting treatment
• Failure to improve requires reevaluation of both diagnosis and therapy
• Persistent swelling or tenderness after completing antimicrobial therapy warrants comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, or fungal epididymitis) 1
• Untreated epididymitis can lead to infertility and chronic scrotal pain 2

Management of Sexual Partners

For cases caused by STIs:

• Refer sexual partners for evaluation and treatment if contact occurred within 60 days of symptom onset
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1

Special Considerations

• HIV-infected patients: Same treatment regimen as HIV-negative patients for uncomplicated epididymitis
• Antimicrobial resistance: Recent studies show high susceptibility of cultured bacteria to fluoroquinolones and group 3 cephalosporins in antibiotic-naive patients (>85%) 4
• Diagnostic advances: Modern molecular techniques have improved pathogen detection rates, with 16S rDNA analysis increasing detection by approximately 10% 4

Common Pitfalls to Avoid

1. Misdiagnosing testicular torsion as epididymitis - always consider torsion, especially in adolescents with sudden-onset pain 3
2. Inadequate antibiotic coverage - using ciprofloxacin alone is not optimal for chlamydial infections 5
3. Failure to refer patients to genitourinary medicine clinics for contact tracing and partner treatment 5
4. Not reevaluating patients who fail to improve within 3 days of treatment initiation 1