Initial Treatment for Epididymitis
The initial treatment for epididymitis should be ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days for sexually active men under 35 years of age. 1
Treatment Recommendations Based on Age and Risk Factors
For Men Under 35 Years
- First-line therapy: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
- This regimen targets the most common pathogens in this age group: Neisseria gonorrhoeae and Chlamydia trachomatis, which account for approximately 78% of cases in younger men 3
For Men Who Have Sex with Men or Practice Insertive Anal Intercourse
- Recommended regimen: Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg daily OR ofloxacin 300 mg twice daily for 10 days 1
- This regimen provides additional coverage for enteric organisms that may cause infection in this population 4
For Men Over 35 Years
- Recommended regimen: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
- This targets enteric bacteria (predominantly E. coli) which are more common in older men due to bladder outlet obstruction and urinary reflux 4
Supportive Care Measures
In addition to antimicrobial therapy, implement:
- Bed rest
- Scrotal elevation
- Analgesics
- Continue these measures until fever and local inflammation subside 1
Diagnostic Approach Prior to Treatment
Before initiating treatment, perform:
- 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 if urethral Gram stain is negative
- Syphilis serology and HIV counseling/testing 1
Important Clinical Considerations
Differential Diagnosis
- Critical: Rule out testicular torsion, which is a surgical emergency
- Be especially vigilant when:
- Pain onset is sudden
- Pain is severe
- There is no evidence of urethritis or UTI
- Patient is an adolescent (higher incidence) 1
Follow-up and Monitoring
- Reevaluate if no improvement occurs within 3 days
- Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for other diagnoses such as tumor, abscess, infarction, testicular cancer, TB, or fungal epididymitis 1
Partner Management
- Refer sex partners for evaluation and treatment if contact occurred within 60 days before symptom onset
- Advise patients to avoid sexual intercourse until they and their partners complete treatment and are asymptomatic 1
Special Populations
- HIV-positive patients with uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients
- Consider fungi and mycobacteria as more likely causes in immunosuppressed patients 1
Treatment Efficacy and Outcomes
- Modern diagnostic techniques have improved pathogen detection rates, with causative organisms identified in up to 88% of antibiotic-naive patients 5
- With appropriate antimicrobial therapy, most cases can be managed conservatively with only about 2.5% of patients requiring surgical intervention (semicastration) 5
- Untreated acute epididymitis can lead to infertility and chronic scrotal pain, emphasizing the importance of prompt and appropriate therapy 4