What is the initial treatment for a patient diagnosed with epididymitis?

Initial Treatment for Epididymitis

For patients diagnosed with epididymitis, the initial treatment should be empiric antimicrobial therapy based on the patient's age and risk factors, with ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 10 days for sexually transmitted infections in younger men, or a fluoroquinolone for older men with suspected enteric organisms. 1

Treatment Algorithm Based on Patient Age and Risk Factors

For patients <35 years (likely STI-related):

• 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 OR with risk factors for enteric organisms:

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

For patients with cephalosporin/tetracycline allergies:

• Ofloxacin 300 mg orally twice daily for 10 days 1

Supportive Measures (for all patients)

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

Diagnostic Considerations

Before initiating treatment, the following diagnostic steps should be performed:

• 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

Etiology and Rationale for Treatment

The causative organisms vary by age and sexual practices:

• In men <35 years: Chlamydia trachomatis and Neisseria gonorrhoeae are the predominant pathogens 1, 3, 4
• In men >35 years: Enteric bacteria (primarily E. coli) are more common, often related to bladder outlet obstruction 3, 5
• In men who practice insertive anal intercourse: Enteric organisms must also be considered 1, 3

Recent studies have shown that a bacterial pathogen can be identified in up to 88% of antibiotic-naive patients, with E. coli accounting for 56% of cases 5. This high rate of bacterial etiology underscores the importance of appropriate antimicrobial therapy.

Follow-Up and Complications

• Patients should be reevaluated if symptoms don't improve within 3 days 1
• Persistent swelling or tenderness after completing antimicrobial therapy requires comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, fungal epididymitis) 1
• Untreated epididymitis can lead to infertility and chronic scrotal pain 3

Management of Sexual Partners

For patients with suspected or confirmed STI-related epididymitis:

• Sex partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic 1

Special Considerations

• HIV-infected patients: Same treatment regimen as HIV-negative patients for uncomplicated epididymitis
• Immunocompromised patients: Consider fungal or mycobacterial etiology if standard therapy fails 1, 6
• Persistent symptoms: Consider needle aspiration with cultures for fungus and viral organisms, especially in immunocompromised patients 6