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. 1, 2
Etiology-Based Treatment Approach
Treatment should be tailored based on the patient's age and likely causative organisms:
For sexually active men under 35 years:
- Primary regimen: Ceftriaxone 250 mg IM (single dose) + Doxycycline 100 mg orally twice daily for 10 days 1, 2
- Targets both Neisseria gonorrhoeae and Chlamydia trachomatis, the most common pathogens in this age group 3
- Alternative regimen: Ofloxacin 300 mg orally twice daily for 10 days 1
- Note: Ofloxacin is contraindicated in patients ≤17 years of age 1
For men who practice insertive anal intercourse:
- Ceftriaxone 250 mg IM (single dose) + Levofloxacin or Ofloxacin for 10 days 3
- Provides coverage for enteric organisms in addition to STIs
For men over 35 years:
- Fluoroquinolone (levofloxacin or ofloxacin) alone for 10 days 3
- Targets enteric bacteria (predominantly E. coli), which are the most common causative organisms in this age group 4
Supportive Measures
In addition to antimicrobial therapy, the following supportive measures are essential:
- Bed rest until fever and local inflammation subside 1
- Scrotal elevation 1, 2
- Adequate analgesics and fluid intake 2
Diagnostic Evaluation
Before initiating treatment, the following diagnostic tests should be performed:
- Gram-stained smear of urethral exudate for N. gonorrhoeae and NGU 1
- Culture of urethral exudate for N. gonorrhoeae 1
- Testing for C. trachomatis 1
- Culture and Gram-stained smear of urine for Gram-negative bacteria 1
Follow-Up and Complications
- Patients should be re-evaluated if no improvement occurs within 3 days 1
- Consider hospitalization if symptoms worsen despite appropriate therapy 1
- Persistent swelling or tenderness after completing antimicrobial therapy warrants evaluation for testicular cancer, tuberculosis, or fungal epididymitis 1
- Potential complications include abscess formation, testicular ischemia, infertility, and chronic scrotal pain 3
Management of Sexual Partners
- Sexual partners of patients with epididymitis caused by STIs should be referred for evaluation and treatment if contact occurred within 30 days of symptom onset 1
- Patients should avoid sexual intercourse until both patient and partner(s) complete treatment and are asymptomatic 1
Special Considerations
- HIV-infected patients with uncomplicated epididymitis should receive the same treatment as HIV-negative individuals 1
- However, fungal and mycobacterial causes are more common in immunocompromised patients 1
Remember that early and appropriate treatment is crucial to prevent complications such as infertility and chronic scrotal pain 3.