What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For epididymitis most likely caused by gonococcal or chlamydial infection (sexually active men <35 years), treatment should consist of ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days. 1

Etiology and Diagnostic Approach

Epididymitis is characterized by inflammation of the epididymis, typically presenting with gradual onset of unilateral testicular pain, swelling, and tenderness. The etiology varies by age:

• Men <35 years: Primarily sexually transmitted infections (STIs)

  • Chlamydia trachomatis and Neisseria gonorrhoeae are the predominant pathogens 2, 3
  • Men who practice insertive anal intercourse may have enteric organisms 3

• Men >35 years: Primarily enteric bacteria

  • Often associated with urinary tract infections or bladder outlet obstruction 2, 3
  • Escherichia coli is the most common pathogen 2

Diagnostic Evaluation

Before initiating treatment, the following tests should be performed:

• Gram-stained smear of urethral exudate or intraurethral swab specimen
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
• Examination of first-void urine for leukocytes if urethral Gram stain is negative
• Syphilis serology and HIV counseling/testing 1

Treatment Recommendations

For Men <35 Years (Likely STI-Related)

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice a day for 10 days 1, 4

For Men >35 Years or Enteric Organisms

• Ofloxacin 300 mg orally twice a day for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days 1, 3

For Patients Allergic to Cephalosporins and/or Tetracyclines

• Ofloxacin 300 mg orally twice a day for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days 1

Adjunctive Measures

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

Follow-Up and Complications

• Reevaluation is necessary if no improvement within 3 days of treatment initiation 1
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation
• Differential diagnosis for persistent symptoms includes:
  • Tumor
  • Abscess
  • Testicular infarction
  • Testicular cancer
  • Tuberculosis
  • Fungal epididymitis 1

Management of Sexual Partners

• Partners of patients with suspected STI-related epididymitis should be referred for evaluation and treatment
• Sexual contact within 60 days preceding symptom onset warrants partner treatment
• Patients should avoid sexual intercourse until:
  • Therapy is completed
  • Both patient and partner(s) are asymptomatic 1

Special Considerations

HIV Infection

• Patients with HIV and uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients
• Fungal and mycobacterial causes are more common in immunocompromised patients 1

Clinical Pitfalls

1. Testicular torsion must be ruled out - a surgical emergency more common in adolescents that presents with sudden onset of severe pain
2. Failure to identify and treat partners can lead to reinfection
3. Untreated epididymitis can lead to infertility and chronic scrotal pain 3
4. C. trachomatis epididymitis is often associated with oligospermia 2, 5

By following these evidence-based treatment guidelines, clinicians can effectively manage epididymitis, prevent complications, and reduce patient morbidity.