What is the treatment for orchitis?

Treatment of Orchitis

The treatment of orchitis requires targeted antimicrobial therapy based on the likely causative organism, with ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 10 days being the recommended regimen for sexually transmitted causes. 1

Diagnosis and Evaluation

Before initiating treatment, it's crucial to differentiate orchitis from other causes of testicular pain, particularly testicular torsion which requires immediate surgical intervention:

• Onset of pain: Orchitis typically has a gradual onset, while torsion presents with sudden, severe pain
• Associated symptoms: Orchitis often presents with fever, dysuria, and urethral discharge
• Physical examination: Look for tender, swollen testis in normal anatomic position with intact cremasteric reflex in orchitis

Diagnostic Tests:

• Gram-stained smear of urethral exudate
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
• Urinalysis and urine culture
• First-void urine examination for leukocytes if urethral Gram stain is negative

Treatment Algorithm

1. For Sexually Transmitted Orchitis (Age <35 years):

• First-line therapy:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 1, 2

2. For Orchitis Likely Caused by Enteric Organisms (Age >35 years or UTI symptoms):

• First-line therapy:
  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1

3. Supportive Measures (for all patients):

• Bed rest
• Scrotal elevation
• Analgesics until fever and local inflammation subside 1

Follow-Up and Monitoring

• Patients should show clinical improvement within 3 days of starting treatment
• If no improvement occurs within 72 hours, reevaluation is necessary to:
  1. Confirm diagnosis
  2. Consider alternative diagnoses (tumor, abscess, infarction, testicular cancer, TB)
  3. Consider surgical intervention if abscesses are present 1, 3

Management of Sexual Partners

For sexually transmitted orchitis:

• Sexual partners within the past 60 days should be referred for evaluation and treatment
• Patients should avoid sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic 1

Special Considerations

HIV Infection

• Patients with HIV should receive the same treatment regimen as HIV-negative patients
• Be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Complications

• Potential complications include abscess formation, testicular ischemia, infertility, and chronic scrotal pain
• Persistent swelling after antimicrobial therapy requires comprehensive evaluation 1, 3

Pitfalls to Avoid

1. Misdiagnosing testicular torsion: Always consider torsion in cases of sudden, severe testicular pain, especially in adolescents
2. Inadequate testing: Only 50.1% of men diagnosed with epididymo-orchitis are tested for gonorrhea and chlamydia 4
3. Delayed treatment: Prompt initiation of appropriate antibiotics is essential to prevent complications
4. Overlooking surgical indications: Patients who don't improve with antibiotics within 48-72 hours may require surgical intervention 3

Remember that chlamydia is the most common sexually transmitted infection in men under 35 years diagnosed with orchitis, while E. coli is the most common bacteria found in urine cultures of affected patients 4.