Treatment of Epididymitis
For epididymitis treatment, the recommended first-line therapy is ceftriaxone 1g IM or IV single dose PLUS doxycycline 100mg orally twice daily for 10 days in sexually active men under 35 years, while men over 35 years should receive fluoroquinolones such as levofloxacin 500mg orally once daily for 10 days. 1
Treatment Based on Age and Risk Factors
For sexually active men under 35 years:
First-line treatment:
Alternative regimens:
- Cefixime 400mg orally single dose PLUS azithromycin 1g orally single dose, followed by doxycycline 100mg twice daily for 10 days
- For cephalosporin allergy: Gentamicin 240mg IM single dose PLUS azithromycin 2g orally single dose, followed by doxycycline 1
For men over 35 years:
- First-line treatment:
For men who practice insertive anal intercourse:
- Ceftriaxone with 10 days of oral levofloxacin or ofloxacin (targets both STIs and enteric organisms) 1, 3
Diagnostic Considerations
Ultrasound with Doppler is essential to:
- Confirm diagnosis
- Rule out testicular malignancy or torsion
- Differentiate from other scrotal conditions 1
Key differential diagnosis: Testicular torsion
- Epididymitis: Gradual onset, positive Prehn sign, normal testicular position
- Torsion: Sudden onset, high-riding testicle, absent cremasteric reflex 1
Supportive Care
- Bed rest
- Scrotal elevation
- Analgesics (NSAIDs)
- Adequate fluid intake 1
- Application of heat or cold over the perineum
- Scrotal support 1
Indications for Hospitalization
Consider hospital admission for:
- Severe pain
- Febrile patients
- Patients who might be noncompliant with treatment 1
Surgical Management
Surgical intervention may be necessary for:
- Persistent symptoms despite appropriate antibiotic therapy
- May include scrotal exploration with possible epididymectomy 1
Complications to Monitor
- Abscess formation
- Testicular ischemia (rare)
- Infertility
- Chronic scrotal pain 1
Microbiology Considerations
The microbiology of epididymitis varies by age group:
- Young adults (14-35 years): Primarily N. gonorrhoeae and C. trachomatis 1, 3, 4
- Men over 35 years: Primarily enteric bacteria from urinary tract infections, often associated with bladder outlet obstruction 1, 3
Clinical Pearls
- Epididymitis in children under 14 years is often due to reflux of urine into ejaculatory ducts 3
- Untreated acute epididymitis can lead to infertility and chronic scrotal pain 3
- In cases of suspected chlamydial infection, consider screening and treating sexual partners 5
- Microscopic urethritis is present in over 50% of cases even without visible discharge 4
- Obtain serum tumor markers (β-HCG, AFP, LDH) to rule out testicular malignancy before surgical intervention 1