Treatment for Epididymitis
The recommended treatment for epididymitis depends on the patient's age and likely causative organisms, with ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days being the standard regimen for sexually active men under 35 years. 1
Treatment Algorithm Based on Patient Age and Risk Factors
For men under 35 years or sexually active men with suspected STI etiology:
- First-line treatment:
- Ceftriaxone 250 mg IM in a single dose PLUS
- Doxycycline 100 mg orally twice daily for 10 days 1
For men over 35 years, those with enteric organism infections, or patients allergic to cephalosporins/tetracyclines:
- Recommended regimen:
- Ofloxacin 300 mg orally twice daily for 10 days OR
- Levofloxacin 500 mg orally once daily for 10 days 1
Adjunctive measures for all patients:
- Bed rest
- Scrotal elevation
- Analgesics until fever and local inflammation subside 1
Rationale for Treatment Selection
The treatment approach is based on the most likely causative organisms:
- In men under 35 years: Chlamydia trachomatis and Neisseria gonorrhoeae are the predominant pathogens 2, 3
- In men over 35 years: Enteric bacteria (especially E. coli) are more common, often related to bladder outlet obstruction 2
- In men who practice insertive anal intercourse: Enteric organisms must be considered regardless of age 2
Follow-Up Recommendations
- Patients should be reevaluated if symptoms don't improve within 3 days of starting treatment 1
- Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for other conditions including tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis 1
Management of Sexual Partners
- For cases caused by STIs (C. trachomatis or N. gonorrhoeae):
- Sex partners should be referred for evaluation and treatment
- Partners with contact within 60 days preceding symptom onset should be treated
- Patients should avoid sexual intercourse until both they and their partners complete treatment and are asymptomatic 1
Special Considerations
HIV Infection
- Patients with uncomplicated epididymitis and HIV infection should receive the same treatment regimens as HIV-negative patients
- However, fungal and mycobacterial causes are more common in immunosuppressed patients and should be considered if standard treatment fails 1
Common Pitfalls to Avoid
- Misdiagnosis: Testicular torsion must be ruled out, especially in adolescents, as it's a surgical emergency requiring immediate intervention 1
- Inadequate follow-up: Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
- Incomplete partner treatment: Neglecting to treat sexual partners can lead to reinfection 1
- Inappropriate antibiotic selection: Using antibiotics that don't cover the likely pathogens based on patient age and risk factors 2
The treatment approach outlined above is designed to achieve microbiologic cure, improve symptoms, prevent transmission, and reduce complications such as infertility and chronic pain 2.