What is the recommended treatment for epididymitis?

Treatment of Epididymitis

The recommended treatment for epididymitis is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days for sexually transmitted epididymitis in younger men, while fluoroquinolones (ofloxacin 300 mg orally twice daily or levofloxacin 500 mg orally once daily for 10 days) are recommended for enteric organism-caused epididymitis in older men. 1

Treatment Based on Age and Risk Factors

Young Adults (14-35 years)

• First-line treatment: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
  • Targets both N. gonorrhoeae and C. trachomatis, which are the most common causative organisms in this age group 1, 3
  • Complete the full 10-day course of doxycycline even if symptoms improve earlier 2

Men Over 35 Years

• Recommended treatment: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
  • Targets enteric bacteria, which are common causes in this age group, often associated with bladder outlet obstruction 1, 3

Men Who Practice Insertive Anal Intercourse

• Recommended treatment: Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice daily for 10 days 1
  • Covers both STIs and enteric organisms 1, 3

Supportive Measures

• Bed rest
• Scrotal elevation
• Adequate analgesics
• Adequate fluid intake 1

Follow-up and Partner Treatment

• Microbiologic re-examination 7-10 days after completing therapy
• Consider rescreening for C. trachomatis and N. gonorrhoeae 4-6 weeks after therapy completion 1
• Sex partners should be evaluated and treated empirically with regimens effective against both C. trachomatis and N. gonorrhoeae 1

Special Considerations

Hospitalization Criteria

• Severe pain
• Febrile patients
• Patients who might be noncompliant with treatment 1

Antimicrobial Resistance Considerations

• In non-pretreated patients, bacteria are typically susceptible to fluoroquinolones and group 3 cephalosporins in >85% of cases 4
• In pretreated patients, susceptibility drops significantly (42% for fluoroquinolones, 67% for cephalosporins) 4

Clinical Pearls and Pitfalls

Important Diagnostic Distinctions

• Critical pitfall: Failing to differentiate epididymitis from testicular torsion
  • Epididymitis: Gradual onset, positive Prehn sign, present cremasteric reflex, normal testicular position, increased blood flow on Doppler ultrasound
  • Testicular torsion: Sudden onset, negative Prehn sign, absent cremasteric reflex, high-riding testis, decreased/absent blood flow on Doppler 1

Complications to Monitor

• Abscess formation
• Testicular ischemia (rare)
• Infertility
• Chronic scrotal pain 1
• Oligozoospermia may persist in approximately 20% of cases even after appropriate treatment 5

Diagnostic Approach

• Ultrasound with Doppler is the imaging modality of choice
• Look for increased blood flow, enlarged heterogeneous epididymis, possible testicular enlargement, and possible reactive hydrocele 1

Modern molecular diagnostic techniques have significantly improved pathogen detection, with causative organisms identified in up to 88% of antibiotic-naive patients 4. This underscores the importance of appropriate antimicrobial therapy based on the most likely pathogens according to age and risk factors.