What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For epididymitis in sexually active men under 35 years, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

Etiology and Treatment Based on Age and Risk Factors

Sexually Active Men Under 35 Years

• Most common pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae 1
• Recommended treatment:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 1

Men Who Practice Insertive Anal Intercourse

• Likely pathogens: Enteric organisms in addition to STIs 1, 2
• Recommended treatment:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1

Men Over 35 Years

• Most common pathogens: Enteric bacteria (e.g., E. coli) associated with urinary tract infections 1, 3
• Recommended treatment:
  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1
• Note: Rising fluoroquinolone resistance may necessitate alternative antibiotics in some cases 3

Diagnostic Considerations

Key Clinical Features

• Unilateral testicular pain and tenderness
• Hydrocele and palpable swelling of the epididymis
• Positive Prehn sign (pain relief with scrotal elevation) 4
• Often accompanied by urethritis (may be asymptomatic) 1

Essential Diagnostic Tests

1. Gram-stained smear of urethral exudate/swab for urethritis and 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

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

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

Follow-Up and Complications

• Failure to improve within 3 days requires reevaluation of diagnosis and therapy 1
• Persistent swelling and tenderness after completing antibiotics warrants comprehensive evaluation
• Differential diagnosis for persistent symptoms includes: tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1
• Untreated epididymitis can lead to infertility and chronic scrotal pain 2

Management of Sexual Partners

• For epididymitis caused by STIs, sexual partners should be referred for evaluation and treatment
• Partners should be treated if contact occurred within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until they and their partners complete treatment and are asymptomatic 1

Special Considerations

HIV Infection

• Patients with uncomplicated epididymitis and HIV should receive the same treatment regimen as HIV-negative patients
• Fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Important Clinical Pitfalls

• Do not confuse epididymitis with testicular torsion, which is a surgical emergency
• Testicular torsion presents with sudden onset of severe pain, high-riding testicle, and absent cremasteric reflex 4
• If torsion is suspected, immediate surgical consultation is required without delay for imaging 4