Treatment of Epididymitis
The recommended treatment for epididymitis depends on the patient's age and likely causative organisms, with the standard regimen being ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days for sexually transmitted infections. 1
Etiology and Diagnosis
Epididymitis presents as gradual onset of posterior scrotal pain, often accompanied by urinary symptoms. Physical examination typically reveals:
- Swollen and tender epididymis
- Testis in anatomically normal position
- Positive Prehn sign (pain relief with testicular elevation)
- Present cremasteric reflex 1, 2
These findings help differentiate epididymitis from testicular torsion, which presents with sudden onset of pain, absent cremasteric reflex, and high-riding testis. Doppler ultrasound shows increased blood flow in epididymitis versus decreased/absent flow in torsion. 1
Treatment Algorithm Based on Age and Risk Factors
1. 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, 3
- Target organisms: Neisseria gonorrhoeae and Chlamydia trachomatis
- For men who practice insertive anal intercourse: Add coverage for enteric organisms with ceftriaxone plus levofloxacin 500 mg daily or ofloxacin 300 mg twice daily for 10 days 1, 2
2. Men over 35 years
- First-line treatment: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 4
- Target organisms: Enteric bacteria (often associated with bladder outlet obstruction)
- Note: Rising fluoroquinolone resistance may necessitate alternative antibiotics with good penetration into genital tissues 4
3. Children under 14 years
- Etiology often related to reflux of urine into ejaculatory ducts 2
- Treatment should be guided by urine culture results
Supportive Measures
In addition to antibiotics, supportive care is essential:
- Bed rest
- Scrotal elevation
- Adequate analgesia (NSAIDs)
- Adequate fluid intake 1
Special Considerations
- Hospitalization criteria: Severe pain, fever, or concerns about treatment compliance 1
- Chronic epididymitis (symptoms >3 months) may require specialized management approaches including:
- Amitriptyline (starting at 10mg and titrating to 75-100mg) for neuropathic pain
- Application of heat or cold over the perineum
- Scrotal support/elevation 1
Potential Complications
Untreated acute epididymitis can lead to:
Follow-up Care
Regular monitoring is important to:
- Ensure resolution of infection
- Assess for recurrence
- Evaluate for any underlying conditions (e.g., bladder outlet obstruction in older men) 1
Treatment Efficacy
Studies show that appropriate antibiotic therapy leads to eradication of causative organisms in most cases, though local symptoms may persist for weeks. In one study using ofloxacin, eradication of causative organisms was achieved in 16 of 20 cases after 12 weeks, though local pain and swelling persisted in 6 patients. 5