What is the initial treatment for orchiepididymitis?

Initial Treatment for Orchiepididymitis

The initial treatment for orchiepididymitis should be empiric antimicrobial therapy based on the patient's age and likely causative organism, with ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days for patients under 35 years, and ofloxacin 300 mg or levofloxacin 500 mg orally twice daily for 10 days for patients over 35 years. 1

Etiology and Diagnostic Approach

The causative organisms for orchiepididymitis vary by age group:

• Patients <35 years: Primarily sexually transmitted pathogens

  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Often accompanied by urethritis (which may be asymptomatic)

• Patients >35 years: Primarily enteric organisms

  • Gram-negative bacteria (e.g., E. coli)
  • Associated with urinary tract infections, recent instrumentation, or anatomical abnormalities

Before initiating treatment, diagnostic evaluation should include:

• 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
• Culture and Gram-stained smear of urine for Gram-negative bacteria
• Syphilis serology and HIV counseling/testing 1

Treatment Algorithm

For patients <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 patients >35 years (likely enteric organisms) OR patients allergic to cephalosporins/tetracyclines:

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

Adjunctive measures (for all patients):

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

Follow-Up and Complications

• Reevaluation is necessary if no improvement occurs within 3 days
• Persistent swelling or tenderness after completing antimicrobial therapy requires comprehensive evaluation
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 1

Management of Sexual Partners

For patients with STI-related orchiepididymitis:

• Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until both they and their partners complete treatment and are asymptomatic 1

Special Considerations

HIV Infection

• Patients with uncomplicated orchiepididymitis and HIV infection should receive the same treatment regimen as HIV-negative patients
• However, fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Tuberculous Orchiepididymitis

• Consider this diagnosis in cases not responding to conventional antibiotics
• Diagnosis may require molecular methods like nucleic acid amplification tests
• Treatment requires specific antituberculous therapy 3

Clinical Pitfalls and Caveats

1. Differentiate from testicular torsion: Testicular torsion is a surgical emergency that can be confused with orchiepididymitis. Consider torsion particularly in adolescents, when pain onset is sudden and severe, or when there's no evidence of urethritis or UTI 1, 4

2. Consider hospitalization for patients with:

   • Severe pain suggesting alternative diagnoses
   • Febrile patients
   • Patients who might be non-compliant with treatment 1

3. Watch for complications: Untreated or inadequately treated orchiepididymitis can lead to abscess formation, testicular ischemia, infertility, and chronic scrotal pain 5