Treatment of Left Epididymoorchitis
For epididymoorchitis most likely caused by sexually transmitted infections in 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. For men over 35 years or when enteric organisms are suspected, ofloxacin 300 mg orally twice daily for 10 days or levofloxacin 500 mg orally once daily for 10 days is recommended. 1
Diagnostic Approach
Before initiating treatment, it's crucial to differentiate epididymoorchitis from testicular torsion, which is a surgical emergency. Key diagnostic considerations include:
- Clinical presentation: Epididymoorchitis typically presents with gradual onset of unilateral testicular pain and tenderness, with palpable swelling of the epididymis 1
- Positive Prehn sign: Pain relief with testicular elevation (present in epididymoorchitis, absent in torsion) 2
- Cremasteric reflex: Present in epididymoorchitis, absent in testicular torsion 2
- Doppler ultrasound: Shows increased blood flow in epididymoorchitis versus decreased/absent flow in torsion 2
Treatment Algorithm
1. For men <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 men >35 years or enteric organism suspicion:
- Ofloxacin 300 mg orally twice daily for 10 days
- OR
- Levofloxacin 500 mg orally once daily for 10 days 1
3. Adjunctive measures:
- Bed rest
- Scrotal elevation
- Analgesics until fever and local inflammation subside 1
Etiological Considerations
The etiology of epididymoorchitis varies by age:
- In men <35 years: Most commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae 1
- In men >35 years: Usually caused by enteric organisms (predominantly E. coli) 3, 4
- Risk factors for enteric organism infection include recent urinary tract instrumentation, surgery, or anatomical abnormalities 1
Follow-Up and Complications
- Patients should show clinical improvement within 3 days of starting treatment 1
- Failure to improve requires reevaluation of diagnosis and therapy 1
- Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for other conditions including tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 1
- Potential complications include abscess formation, testicular ischemia, infertility, and chronic scrotal pain 5
Management of Sexual Partners
For cases caused by STIs:
- Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
- Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1
Special Considerations
- HIV-infected patients: Same treatment regimen as HIV-negative patients, though fungal and mycobacterial causes are more common in immunosuppressed patients 1
- Hospitalization: Consider for patients with severe pain, fever, or concern for medication non-compliance 1
- Fluoroquinolone resistance: Rising resistance to ciprofloxacin in E. coli isolates may necessitate alternative antimicrobials for treating epididymoorchitis caused by enteric organisms 3