What is the recommended treatment for epididymoorchitis?

Treatment of Epididymoorchitis

For epididymitis most likely caused by gonococcal or chlamydial infection (typically in men <35 years), the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days. 1

Diagnosis and Evaluation

Proper diagnosis is essential before initiating treatment:

• Clinical presentation: Unilateral testicular pain and tenderness with gradual onset, often accompanied by urinary symptoms (dysuria, frequency)
• Physical findings: Swollen and tender epididymis with testis in anatomically normal position 2
• Diagnostic tests should include:
  • Gram-stained smear of urethral exudate for diagnosis of urethritis
  • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
  • Examination of first-void urine for leukocytes if urethral Gram stain is negative
  • Syphilis serology and HIV counseling/testing 1

Treatment Algorithm Based on Age and Risk Factors

1. Men <35 years (sexually transmitted pathogens likely)

• First-line treatment:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days 1

2. Men >35 years OR enteric organisms suspected OR allergies to cephalosporins/tetracyclines

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

3. Men who practice insertive anal intercourse (enteric organisms likely)

• First-line treatment:
  • Ceftriaxone with 10 days of oral levofloxacin or ofloxacin 2

Adjunctive Measures

In addition to antimicrobial therapy, the following supportive measures are recommended:

• Bed rest
• Scrotal elevation
• Analgesics
• Continue until fever and local inflammation have subsided 1

Follow-Up and Complications

• Patients should be reevaluated if no improvement occurs within 3 days of treatment initiation
• Persistent swelling or tenderness after completing antimicrobial therapy requires comprehensive evaluation
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis 1

Special Considerations

HIV Infection

• Patients with uncomplicated epididymitis who are HIV-positive should receive the same treatment regimen as HIV-negative patients
• Be aware that fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients 1

Rising Fluoroquinolone Resistance

• Increasing resistance to ciprofloxacin in E. coli isolates in Europe and the USA necessitates consideration of alternative antimicrobials with adequate penetration into genital tissues 3

Management of Sexual Partners

• Partners of patients with epididymitis caused by N. gonorrhoeae or C. trachomatis should be referred for evaluation and treatment
• This applies to partners with contact within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1

Common Pitfalls and Caveats

1. Misdiagnosis of testicular torsion: Testicular torsion is a surgical emergency that must be ruled out in all cases of acute testicular pain, especially in adolescents. Torsion presents with sudden onset of severe pain, while epididymitis typically has a more gradual onset 4, 2

2. Inadequate treatment duration: Complete the full course of antibiotics even if symptoms improve quickly to prevent chronic infection and complications

3. Failure to identify underlying causes: In men >35 years, investigate for potential bladder outlet obstruction (BPH, urethral stricture) that may contribute to epididymitis 3, 4

4. Overlooking STIs in older adults: As demonstrated by case reports, gonococcal epididymo-orchitis can occur even in octogenarians, highlighting the importance of obtaining a sexual history regardless of age 5