Treatment of Testicular Cellulitis
The treatment of testicular cellulitis requires prompt antibiotic therapy with ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for 10 days for cases likely caused by sexually transmitted pathogens, or fluoroquinolones (ofloxacin 300 mg or levofloxacin 500 mg) orally twice daily for 10 days for cases likely caused by enteric organisms. 1
Diagnostic Approach
Before initiating treatment, proper diagnosis is crucial:
- Distinguish from testicular torsion: Sudden onset of severe pain without signs of inflammation suggests torsion, which is a surgical emergency requiring immediate specialist consultation
- Evaluate for urethritis: Perform Gram-stained smear of urethral exudate (>5 polymorphonuclear leukocytes per oil immersion field indicates urethritis)
- Obtain cultures: Collect urethral exudate or intraurethral swab specimens for N. gonorrhoeae and C. trachomatis
- Examine urine: First-void urine for leukocytes if urethral Gram stain is negative
- Additional testing: Syphilis serology and HIV counseling/testing
Treatment Algorithm
1. For patients <35 years or sexually transmitted infection suspected:
- First-line therapy:
- Ceftriaxone 250 mg IM in a single dose, PLUS
- Doxycycline 100 mg orally twice daily for 10 days 1
2. For patients >35 years, enteric organisms suspected, or allergies to first-line agents:
- Alternative therapy:
- Ofloxacin 300 mg orally twice daily for 10 days, OR
- Levofloxacin 500 mg orally once daily for 10 days 1
3. Adjunctive measures:
- Bed rest
- Scrotal elevation
- Analgesics until fever and local inflammation subside 1
Special Considerations
Hospitalization Criteria
Consider inpatient management when:
- Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess)
- Patient is febrile
- Concerns about medication adherence exist 1
Treatment Failure
- Reevaluate diagnosis and therapy if no improvement within 3 days
- Consider alternative diagnoses if swelling and tenderness persist after completing antibiotics:
- Tumor
- Abscess
- Infarction
- Testicular cancer
- Tuberculosis
- Fungal epididymitis 1
Management of Sex Partners
- For cases caused by STIs, refer sex partners for evaluation and treatment
- Partners should be referred if contact occurred within 60 days preceding symptom onset
- Advise abstinence from sexual intercourse until both patient and partner(s) complete treatment and are asymptomatic 1
Severe Cases with Skin Involvement
In cases of rapidly progressive cellulitis with skin involvement:
- Immediate decompression with linear incisions may be necessary if there is intense swelling to prevent skin devascularization
- Radical debridement may be required if gangrene develops 2
Monitoring Response
- Expect improvement within 72 hours of starting appropriate antibiotics
- If no improvement after 72 hours, consider:
- Reevaluation of diagnosis
- Change in antibiotic therapy
- Drainage procedure if abscess has formed 3
Evidence Quality and Considerations
The treatment recommendations are primarily based on CDC guidelines, which represent the highest quality evidence available for this condition. While some research suggests potential benefits of adding anti-inflammatory medications to antibiotic therapy for cellulitis in general 4, this approach has not been specifically validated for testicular cellulitis and should not replace standard antibiotic therapy.
Recent research indicates that antibiotics with activity against MRSA (such as trimethoprim-sulfamethoxazole) may be preferred in areas with high MRSA prevalence 5, but the CDC guidelines remain the standard of care for initial empiric therapy of testicular cellulitis.