What is the treatment for epididymitis?

Treatment for Epididymitis

The treatment for epididymitis depends on the likely causative organism, which varies by age and risk factors, with the standard regimen being ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 10 days for sexually transmitted cases. 1

Antimicrobial Treatment Based on Age and Risk Factors

For patients likely infected with sexually transmitted pathogens (age <35 years):

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

For patients likely infected with enteric organisms (age >35 years, recent urinary tract instrumentation, or insertive anal intercourse):

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

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days 1

Supportive Measures

In addition to antimicrobial therapy, the following supportive measures are recommended:

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

Causative Organisms by Age Group

The choice of antimicrobial therapy is based on the most likely causative organisms:

• Age <35 years: Primarily Chlamydia trachomatis and Neisseria gonorrhoeae 2, 3, 4

  • C. trachomatis accounts for approximately two-thirds of idiopathic epididymitis in young men 3, 5
  • N. gonorrhoeae is detected in up to 57% of cases in some populations 4

• Age >35 years: Primarily enteric organisms, especially Escherichia coli 2, 6

  • E. coli is isolated from urine in about 30% of older patients compared to 3% in younger patients 4

Follow-Up Recommendations

• Patients should be reevaluated if symptoms do not improve within 3 days of starting treatment 1
• Persistent swelling or tenderness after completing antimicrobial therapy requires comprehensive evaluation
• The differential diagnosis for persistent symptoms includes:
  • Tumor
  • Abscess
  • Infarction
  • Testicular cancer
  • Tuberculosis
  • Fungal epididymitis 1

Management of Sexual Partners

• For cases caused by N. gonorrhoeae or C. trachomatis, sexual partners should be referred for evaluation and treatment
• Partners with contact within 60 days preceding symptom onset should be evaluated
• Patients and partners should avoid sexual intercourse until therapy is completed and symptoms have resolved 1

Special Considerations

• HIV-infected patients: Same treatment regimen as HIV-negative patients
• Caution: Immunosuppressed patients are more likely to have fungal or mycobacterial infections causing epididymitis 1
• Complications: Untreated acute epididymitis can lead to infertility and chronic scrotal pain 2

Remember that prompt and appropriate antimicrobial therapy is essential to prevent complications such as infertility and chronic pain.