What is the treatment for epididymitis?

Treatment of Epididymitis

For epididymitis, the treatment regimen should be based on the patient's age and likely causative organisms, with ceftriaxone plus doxycycline for sexually transmitted causes in younger men, and fluoroquinolones for enteric organisms in older men. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Unilateral testicular pain and tenderness with palpable swelling of the epididymis
• Differentiate from testicular torsion (surgical emergency) which presents with:
  • Sudden onset of severe pain
  • High-riding testis
  • Absent cremasteric reflex
  • More common in adolescents

Diagnostic tests should include:

• Gram-stained smear of urethral exudate
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
• Examination of first-void urine for leukocytes
• Syphilis serology and HIV counseling/testing

Treatment Algorithm Based on Age and Risk Factors

For men under 35 years (likely STI-related):

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 1, 2

For men over 35 years OR with enteric organism risk factors:

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

For men who practice insertive anal intercourse:

• Ceftriaxone 250 mg IM in a single dose PLUS
• Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 3

For patients allergic to cephalosporins and/or tetracyclines:

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

Supportive Measures

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

Follow-Up Considerations

• Reevaluate if no improvement within 3 days
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation
• Consider alternative diagnoses: tumor, abscess, infarction, testicular cancer, TB, or fungal epididymitis 1

Management of Sex Partners

• For STI-related epididymitis, refer sex partners for evaluation and treatment
• Partners should be referred if contact occurred within 60 days preceding symptom onset
• Avoid sexual intercourse until therapy is completed and symptoms have resolved 1

Special Considerations

Immunocompromised Patients

• HIV-infected patients with uncomplicated epididymitis should receive the same treatment as HIV-negative patients
• Be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1, 4

Rising Antimicrobial Resistance

• Increasing fluoroquinolone resistance in enteric organisms may necessitate alternative treatments in some regions 5
• Consider local resistance patterns when selecting antibiotics

Common Pitfalls to Avoid

1. Misdiagnosing testicular torsion (surgical emergency) as epididymitis
2. Failing to test for both STIs and urinary pathogens
3. Not addressing underlying causes (e.g., urinary tract abnormalities, prostatic hyperplasia)
4. Inadequate follow-up for patients not responding to initial therapy
5. Neglecting to treat sexual partners in STI-related cases

Early and appropriate treatment is vital to prevent complications such as infertility, chronic scrotal pain, and abscess formation 3.