What is the treatment for epididymitis?

Treatment of Epididymitis

For epididymitis, the treatment should be targeted based on patient age and likely causative organisms, with ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 10 days for sexually active men under 35 years, and fluoroquinolones for men over 35 years or those with enteric infections. 1

Etiology and Diagnosis

Epididymitis is inflammation of the epididymis that typically presents with:

• Unilateral testicular pain with gradual onset
• Swelling and tenderness of the epididymis
• Possible urinary symptoms (dysuria, frequency)
• Normal anatomical position of the testis

The cause of epididymitis varies by age group:

• Men <35 years: Primarily sexually transmitted infections (STIs) - Chlamydia trachomatis and Neisseria gonorrhoeae 1, 2
• Men who practice insertive anal intercourse: Enteric organisms in addition to STIs 1
• Men >35 years: Usually enteric bacteria from urinary tract infections, often associated with bladder outlet obstruction 1, 2

Diagnostic Evaluation

The following tests 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

Treatment Regimens

For sexually active men <35 years (likely STI-related):

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 1, 3

For men >35 years, those allergic to cephalosporins/tetracyclines, or likely enteric infections:

• Ofloxacin 300 mg orally twice daily for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days 1

Adjunctive measures:

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

Management of Sex Partners

• Partners of patients with STI-related epididymitis should be referred for evaluation and treatment
• Sexual contact within 60 days preceding symptom onset warrants partner treatment
• Patients should avoid sexual intercourse until they and their partners complete treatment and are asymptomatic 1

Follow-Up and Complications

• Critical warning sign: Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation
• Differential diagnosis for persistent symptoms includes:
  • Tumor
  • Abscess
  • Testicular infarction
  • Testicular cancer
  • Tuberculous or fungal epididymitis 1

Special Considerations

HIV Infection

• Patients with uncomplicated epididymitis and HIV should receive the same treatment regimen as HIV-negative patients
• Fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Hospitalization Criteria

Consider inpatient management when:

• Severe pain suggests alternative diagnoses (torsion, infarction, abscess)
• Patient is febrile
• Concerns about medication compliance exist 1

Important Clinical Pitfalls

1. Don't miss testicular torsion: A surgical emergency that occurs more frequently in adolescents and presents with sudden onset of severe pain. Emergency evaluation is required when pain is severe or sudden in onset 1

2. Beware of antibiotic resistance: In pretreated patients, bacterial susceptibility to fluoroquinolones and cephalosporins may be reduced 4

3. Age is not a perfect predictor of etiology: While STIs are more common in younger men, recent studies show they can occur in any age group 4

4. Don't assume viral etiology: Despite previous beliefs, viral epididymitis appears to be rare, with bacterial causes predominating even in pretreated patients 4