What is the recommended treatment for orchitis?

Treatment of Orchitis

The recommended treatment for orchitis is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days, along with supportive measures including bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Rule out testicular torsion (surgical emergency) - especially in adolescents with sudden onset of severe pain 1
• Perform 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 Likely Etiology

For orchitis most likely caused by sexually transmitted infections (men <35 years):

• First-line treatment:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days 2, 1, 3

For orchitis most likely caused by enteric organisms (men >35 years) or for patients allergic to cephalosporins/tetracyclines:

• Alternative treatment:
  • Ofloxacin 300 mg orally twice a day for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 2, 1

Note: Rising fluoroquinolone resistance in enteric organisms (particularly E. coli) may limit the effectiveness of these alternatives in some regions 4

Supportive Measures (Essential for All Patients)

• 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

• Reassess within 3 days of treatment initiation
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 2, 1
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, fungal epididymitis) 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 2, 1
• Hospitalization criteria: Consider for patients with severe pain, high fever, or concerns about medication compliance 1

Partner Management

• Sex partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until they and their partners complete therapy and are symptom-free 1

Treatment Complications and Pitfalls

• Failure to differentiate from testicular torsion can lead to testicular loss
• Inadequate treatment may result in complications such as infertility, chronic scrotal pain, abscess formation, and testicular infarction
• Complete adherence to the full course of antibiotics is critical to prevent complications 1