What is the initial treatment for a patient with orchitis?

Initial Treatment for Orchitis

For patients with orchitis, the initial treatment should include appropriate antibiotics based on age and likely causative organisms, along with supportive measures including bed rest, scrotal elevation, and analgesics. 1

Diagnostic Evaluation

Before initiating treatment, a proper diagnostic evaluation is essential to confirm orchitis and rule out testicular torsion:

• Urgent assessment: Rule out testicular torsion, especially with sudden onset of severe pain 2, 1
• Laboratory tests:
  • Gram-stained smear of urethral exudate or intraurethral swab
  • Culture or nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis
  • First-void urine examination for leukocytes
  • Urine culture and Gram-stained smear
  • Syphilis serology and HIV testing 1

Treatment Algorithm Based on Age

For Patients Under 35 Years:

• Primary causative organisms: N. gonorrhoeae and C. trachomatis (sexually transmitted infections) 1, 3
• Recommended treatment:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 2, 1, 4

For Patients Over 35 Years:

• Primary causative organisms: Enteric bacteria, especially E. coli 1, 5
• Recommended treatment:
  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 2, 1

Supportive Measures

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

• Bed rest until fever and local inflammation subside
• Scrotal elevation to reduce pain and swelling
• Analgesics for pain management
• Adequate fluid intake with medications 1

Follow-up and Monitoring

• Patients should be reassessed within 3 days of treatment initiation
• If no improvement occurs within 3 days, reevaluation of both diagnosis and therapy is necessary
• Persistent swelling and tenderness after completing antimicrobial therapy require comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, fungal epididymitis) 2, 1

Special Considerations

• HIV-infected patients with uncomplicated orchitis should receive the same treatment regimen as immunocompetent patients, but be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 2, 1
• Partner management: Sex partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
• Sexual activity: Patients should avoid sexual intercourse until they and their partners complete therapy and are symptom-free 1

Common Pitfalls to Avoid

• Misdiagnosis of testicular torsion: This is a surgical emergency requiring immediate intervention; if diagnosis is questionable, consult a specialist immediately 1
• Inadequate follow-up: Failure to improve within 3 days requires reevaluation 2
• Incomplete treatment: Ensure full course of antibiotics is completed to prevent complications like infertility, chronic scrotal pain, abscess formation, and testicular infarction 1
• Overlooking rare causes: In endemic areas, consider brucellosis as a potential cause of orchitis 6

By following this treatment algorithm based on patient age and likely causative organisms, along with appropriate supportive measures, most cases of orchitis can be effectively managed with good outcomes.