Treatment of Epididymitis
For epididymitis, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days for cases likely caused by sexually transmitted infections, while ofloxacin 300 mg orally twice a day for 10 days is recommended for cases likely caused by enteric organisms. 1
Etiology-Based Treatment Algorithm
1. For patients ≤35 years (likely STI-related):
- First-line therapy: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1
- This regimen targets the most common causative organisms in this age group: Neisseria gonorrhoeae and Chlamydia trachomatis 1, 2
- Studies show these pathogens are present in up to 78% of younger patients with epididymitis 3
2. For patients >35 years (likely enteric organism-related):
- First-line therapy: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
- These regimens target enteric organisms commonly causing epididymitis in older men, often associated with bladder outlet obstruction 1, 2
3. For men who practice insertive anal intercourse:
- First-line therapy: Ceftriaxone 250 mg IM single dose PLUS levofloxacin or ofloxacin for 10 days 2
- This combination covers both STIs and enteric organisms 2
Diagnostic Evaluation
Before initiating treatment, perform:
- Gram-stained smear of urethral exudate/swab for urethritis diagnosis and presumptive gonococcal infection 1
- Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
- Examination of first-void urine for leukocytes if urethral Gram stain is negative 1
- Syphilis serology and HIV testing 1
Adjunctive Therapy
- Bed rest
- Scrotal elevation
- Analgesics
- Continue these measures until fever and local inflammation subside 1
Follow-Up and Monitoring
- Reassess within 3 days of treatment initiation 1
- If no improvement occurs within 3 days, reevaluate both diagnosis and therapy 1
- Consider testicular torsion (surgical emergency) if pain is sudden, severe, or diagnostic tests don't support infection 1
- Persistent swelling/tenderness after completing antibiotics requires comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, fungal epididymitis) 1
Partner Management
- Refer sex partners for evaluation and treatment if contact occurred within 60 days before symptom onset 1
- Patients should avoid sexual intercourse until they and their partners complete therapy and are symptom-free 1
Special Considerations
- HIV-infected patients: Same treatment regimen as immunocompetent patients, but be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1
- Hospitalization: Consider for severe pain suggesting other diagnoses, fever, or concerns about medication compliance 1