What is the recommended treatment for epididymitis?

Treatment of Epididymitis

The recommended first-line treatment for epididymitis is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, targeting both N. gonorrhoeae and C. trachomatis. 1

Treatment Based on Age and Risk Factors

Treatment should be tailored based on the patient's age and risk factors:

Young Adults (14-35 years)

• First-line: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This regimen targets the most common causative organisms in this age group: N. gonorrhoeae and C. trachomatis 1, 3

Men Who Practice Insertive Anal Intercourse

• Recommended regimen: Ceftriaxone 250 mg IM single dose PLUS either levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
• This covers both STIs and enteric organisms that are common in this population 1, 3

Men Over 35 Years

• Recommended regimen: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
• This targets enteric bacteria from urinary tract infections, often associated with bladder outlet obstruction 1, 3

Supportive Measures

In addition to antimicrobial therapy, supportive measures are essential:

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

Special Considerations

• Hospitalization should be considered for:

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

• Diagnostic differentiation from testicular torsion is critical:

  • Epididymitis typically has gradual onset of pain
  • Positive Prehn sign (pain relief with elevation)
  • Present cremasteric reflex
  • Normal testicular position
  • Increased blood flow on Doppler ultrasound 1

Treatment Efficacy and Follow-up

• Recent studies show that even in antimicrobially pretreated patients, epididymitis is mainly of bacterial origin, with pathogens identified in 51% of pretreated cases and 88% of antibiotic-naive cases 4
• Bacterial susceptibility to fluoroquinolones and group 3 cephalosporins is >85% in antibiotic-naive patients 4
• Follow-up is important to ensure resolution of symptoms and to prevent complications such as infertility and chronic scrotal pain 3

Common Pitfalls

1. Misdiagnosis: Failing to differentiate epididymitis from testicular torsion, which is a surgical emergency requiring intervention within 6-8 hours 1

2. Age-based assumptions: STIs are not limited to patients aged <35 years, though they are more common in this group 4

3. Inadequate treatment duration: Full 10-day course of antibiotics is necessary even if symptoms improve earlier 1, 2

4. Missing microscopic urethritis: In 53% of patients, urethritis may be diagnosed only by the presence of inflammatory cells in endourethral smears without visible discharge 5

5. Overlooking complications: Untreated acute epididymitis can lead to abscess formation, testicular ischemia, infertility, and chronic scrotal pain 1, 3