Treatment of Epididymitis in Men
For men with epididymitis, the treatment should be ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days if sexually transmitted, or a fluoroquinolone (ofloxacin 300 mg twice daily or levofloxacin 500 mg once daily for 10 days) if likely caused by enteric organisms. 1
Clinical Presentation and Diagnosis
Epididymitis typically presents with:
- Unilateral testicular pain and tenderness
- Hydrocele and palpable swelling of the epididymis
- Gradual onset of symptoms (unlike testicular torsion)
- May be accompanied by urethritis (often asymptomatic)
Diagnostic Evaluation
The evaluation should include:
- Gram-stained smear of urethral exudate for diagnosis of urethritis and presumptive diagnosis of gonococcal infection
- 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
- Culture and Gram-stained smear of uncentrifuged urine
- Syphilis serology and HIV counseling/testing 1
Treatment Algorithm Based on Age and Risk Factors
For men <35 years old or sexually active men:
Epididymitis is most commonly caused by sexually transmitted infections:
- C. trachomatis
- N. gonorrhoeae
- Treatment: Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1
For men >35 years old, men with urinary tract instrumentation/surgery, or men with anatomical abnormalities:
Epididymitis is more likely caused by enteric organisms:
- E. coli and other gram-negative bacteria
- Treatment: Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 1, 2
For men who practice insertive anal intercourse:
Consider both STI pathogens and enteric organisms:
- Treatment: Ceftriaxone 250 mg IM in a single dose PLUS Levofloxacin or Ofloxacin for 10 days 3
Adjunctive Measures
In addition to antimicrobial therapy:
- Bed rest
- Scrotal elevation
- Analgesics
- Continue until fever and local inflammation have subsided 1
Follow-Up and Complications
- Failure to improve within 3 days requires reevaluation of both diagnosis and therapy
- Persistent swelling and tenderness after completing antibiotics warrants comprehensive evaluation
- Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 1
- Untreated acute epididymitis can lead to infertility and chronic scrotal pain 3
Management of Sexual Partners
For patients with epididymitis caused by STIs:
- Refer sex partners for evaluation and treatment
- Partners should be referred if contact occurred within 60 days preceding symptom onset
- Patients should avoid sexual intercourse until they and their partners complete treatment and are asymptomatic 1
Special Considerations
HIV Infection
- Patients with uncomplicated epididymitis and HIV 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
Hospitalization Criteria
Consider hospitalization when:
- Severe pain suggests other diagnoses (torsion, testicular infarction, abscess)
- Patient is febrile
- Patient might be noncompliant with antimicrobial regimen 1
Important Clinical Pitfalls
Misdiagnosis of testicular torsion: Testicular torsion is a surgical emergency that can be confused with epididymitis. Consider torsion especially in adolescents, when pain onset is sudden and severe, or when there's no evidence of infection. If diagnosis is questionable, consult a specialist immediately 1.
Inadequate pathogen coverage: Treatment failure can occur if the causative organism is not covered by the selected antibiotic regimen. Consider patient age and risk factors when selecting therapy 3.
Rising antibiotic resistance: Increasing resistance to fluoroquinolones among E. coli isolates may affect treatment success in cases caused by enteric organisms 2.
Neglecting partner treatment: Failure to evaluate and treat sexual partners can lead to reinfection and persistent symptoms 1.