What is the initial treatment for a patient presenting with orchitis?

Initial Treatment for Orchitis

For patients presenting with orchitis, the initial treatment should include antibiotics targeting the most likely pathogens, specifically ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days for patients under 35 years of age or with suspected sexually transmitted infections. 1

Diagnosis and Assessment

Before initiating treatment, it's important to establish the diagnosis of orchitis and rule out other conditions requiring urgent intervention, particularly testicular torsion:

• Key clinical features: Gradual onset of scrotal pain, swelling, tenderness, and symptoms of lower urinary tract infection including fever
• Physical examination: Swollen, tender testis in normal anatomic position with intact ipsilateral cremasteric reflex
• Laboratory tests:
  • Urethral Gram stain
  • Urinalysis and urine culture
  • Nucleic acid amplification testing (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae 2
  • Complete blood count

Treatment Algorithm Based on Age and Risk Factors

For patients <35 years or with high-risk sexual behaviors:

• Primary pathogens: C. trachomatis and N. gonorrhoeae 3
• Recommended regimen:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days 1, 4

For patients ≥35 years or with urinary tract abnormalities:

• Primary pathogens: Coliform bacteria (especially E. coli) 3
• Recommended regimen:
  • Ofloxacin 300 mg orally twice a day for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1

Supportive Measures

In addition to antimicrobial therapy, the following supportive measures are essential:

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

Follow-Up Recommendations

• Patients should show improvement within 3 days of treatment initiation
• If no improvement occurs within 3 days, reevaluation of both diagnosis and therapy is required
• Persistent swelling and tenderness after completion of antimicrobial therapy warrants comprehensive evaluation for other conditions including tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1

Management of Sexual Partners

For patients with orchitis caused by sexually transmitted pathogens:

• Sexual partners within the preceding 60 days should be referred for evaluation and treatment
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1

Special Considerations

• HIV-infected patients: Same treatment regimens as HIV-negative patients, but be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1
• Mumps orchitis: Supportive care is the mainstay of treatment as this is a viral cause
• Rare causes: Consider varicella orchitis and other viral etiologies in patients with corresponding systemic infections 5

Common Pitfalls to Avoid

1. Misdiagnosis of testicular torsion: Torsion presents with sudden onset of pain and requires immediate surgical intervention
2. Inadequate pathogen testing: Only 50.1% of men diagnosed with epididymitis/orchitis are tested for gonorrhea and chlamydia 3
3. Inappropriate antibiotic selection: Treatment should target the most likely pathogens based on patient age and risk factors
4. Insufficient follow-up: Failure to improve within 3 days requires reevaluation

Early and appropriate treatment of orchitis is crucial to prevent complications such as infertility, chronic pain, and testicular atrophy.