What is the recommended treatment for epididymitis or orchitis in men?

Treatment of Epididymitis and Orchitis in Men

For epididymitis and orchitis in men, the recommended treatment should be based on the patient's age and likely causative organism, with ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days for sexually transmitted infections in men under 35 years, and fluoroquinolones for enteric organisms in men over 35 years. 1

Etiology and Diagnosis

Common Causes by Age Group

• Men <35 years: Primarily sexually transmitted infections
  • Chlamydia trachomatis (most common STI cause) 2
  • Neisseria gonorrhoeae
• Men >35 years: Primarily enteric organisms
  • Escherichia coli (most common) 2
  • Associated with urinary tract infections, bladder outlet obstruction, recent instrumentation, or anatomical abnormalities 1

Diagnostic Evaluation

• Unilateral testicular pain and tenderness
• Hydrocele and palpable swelling of epididymis
• Gradual onset of symptoms (helps differentiate from testicular torsion)
• Diagnostic tests should include:
  • Gram-stained smear of urethral exudate
  • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
  • Urinalysis and urine culture
  • Syphilis serology and HIV counseling/testing 1

CAUTION: Testicular torsion must be ruled out as it is a surgical emergency. Consider torsion when pain onset is sudden, severe, or when urethritis/UTI cannot be confirmed. Immediate specialist consultation is required if diagnosis is questionable. 1

Treatment Regimens

For Men <35 Years (Likely STI-Related)

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

For Men >35 Years (Likely Enteric Organisms) or Those Allergic to Cephalosporins/Tetracyclines

• First-line treatment (choose one):
  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1

CAUTION: Rising fluoroquinolone resistance in E. coli may necessitate alternative treatments in some regions. Consider local resistance patterns when selecting therapy. 3

Adjunctive Measures

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

Follow-Up and Management

Clinical Monitoring

• Improvement should occur within 3 days of treatment initiation
• If no improvement after 3 days, reevaluate diagnosis and therapy 1
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for:
  • Tumor
  • Abscess
  • Infarction
  • Testicular cancer
  • Tuberculous or fungal epididymitis 1

Partner Management

• For STI-related epididymitis, refer sex partners for evaluation and treatment
• Partners should be referred if contact occurred within 60 days before symptom onset
• Patients should avoid sexual intercourse until both patient and partner(s) complete therapy and are asymptomatic 1

Special Considerations

HIV Infection

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

Hospitalization Criteria

• Severe pain suggesting alternative diagnoses (torsion, testicular infarction, abscess)
• Febrile patients
• Patients who might be noncompliant with antimicrobial regimen 1

Proper treatment of epididymitis and orchitis is essential to prevent complications such as infertility and chronic scrotal pain. Age-appropriate antibiotic selection targeting the most likely pathogens is key to successful management.