What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For epididymitis, the recommended treatment depends on the patient's age and likely causative organisms, with ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 10 days being the standard regimen for sexually transmitted causes in younger men. 1

Treatment Algorithm Based on Patient Age and Risk Factors

For patients <35 years (likely sexually transmitted infection):

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

For patients >35 years OR enteric organism suspected OR allergies:

• First-line treatment:
  • 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:

• Consider coverage for both STIs and enteric organisms:
  • 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 2

Diagnostic Evaluation

Before initiating treatment, perform:

1. Gram-stained smear of urethral exudate for diagnosis of urethritis and presumptive diagnosis of gonococcal infection
2. Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
3. Examination of first-void urine for leukocytes if urethral Gram stain is negative
4. Syphilis serology and HIV counseling/testing 1

Supportive Measures

As adjuncts to antibiotic therapy:

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

Follow-Up and Complications

• Reevaluate if no improvement within 3 days of treatment initiation
• 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 Sexual Partners

• For suspected STI-related epididymitis, refer sexual partners from the preceding 60 days for evaluation and treatment
• Advise abstinence from sexual intercourse until both patient and partner(s) complete treatment and are asymptomatic 1

Special Considerations

• HIV-infected patients with uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients
• Be aware that immunosuppressed patients are more likely to have fungal or mycobacterial causes of epididymitis 1

Common Pitfalls to Avoid

1. Failing to distinguish between epididymitis and testicular torsion (a surgical emergency)
2. Using inadequate antibiotic coverage for the likely pathogens
3. Not addressing sexual partners in cases of STI-related epididymitis
4. Overlooking the need for reevaluation if symptoms don't improve within 3 days

Research has shown that ciprofloxacin is more effective than pivampicillin for treating epididymitis in men over 40 years of age, with a lower incidence of adverse events 3. However, current guidelines still recommend ofloxacin or levofloxacin as the preferred fluoroquinolones for this age group 1.