What is the recommended treatment for epididymitis?

Treatment of Epididymitis

The recommended treatment for epididymitis 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 treatment for sexually transmitted cases in men under 35 years, while fluoroquinolones (ofloxacin 300 mg twice daily or levofloxacin 500 mg once daily for 10 days) are recommended for men over 35 years or when enteric organisms are suspected. 1

Etiology and Diagnosis

Epididymitis presents with unilateral testicular pain and tenderness, often with palpable swelling of the epididymis and possible hydrocele. The causative organisms vary by age:

• Men under 35 years: Primarily sexually transmitted infections (STIs)

  • Chlamydia trachomatis and Neisseria gonorrhoeae are most common 1, 2

• Men over 35 years: Primarily enteric organisms

  • Escherichia coli and other enteric bacteria, often associated with urinary tract infections 1
  • Risk factors include recent urinary tract instrumentation, surgery, or anatomical abnormalities 1

Diagnostic evaluation should include:

• Gram-stained smear of urethral exudate
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
• Urinalysis and urine culture
• Doppler ultrasound if testicular torsion is suspected 1

Treatment Recommendations

For men under 35 years (likely STI-related):

• Ceftriaxone 250 mg IM in a single dose
• PLUS Doxycycline 100 mg orally twice a day for 10 days 1, 3

For men over 35 years or when enteric organisms are suspected:

• Ofloxacin 300 mg orally twice a day for 10 days
• OR Levofloxacin 500 mg orally once daily for 10 days 1, 3

For men who practice insertive anal intercourse:

• Ceftriaxone with 10 days of oral levofloxacin or ofloxacin (to cover both STIs and enteric organisms) 2

Adjunctive measures:

• Bed rest
• Scrotal elevation
• Analgesics until fever and local inflammation subside 1, 3

Special Considerations

HIV-infected patients:

• Same treatment regimen as HIV-negative patients
• Be aware that fungal and mycobacterial causes are more common in immunosuppressed patients 1, 3

Management of sexual partners:

• For STI-related epididymitis, sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1

Follow-up and Complications

• Clinical improvement should occur within 3 days of starting treatment
• 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 1

Warning Signs Requiring Immediate Attention

• Sudden onset of severe unilateral scrotal pain
• Nausea/vomiting
• High-riding testicle
• Absent cremasteric reflex

These signs suggest testicular torsion, which requires immediate surgical exploration to prevent testicular loss 1.

Treatment Efficacy

Modern diagnostic methods have shown that even in antibiotically pretreated patients, epididymitis is mainly of bacterial origin, with detection rates of causative pathogens in 88% of antibiotic-naive patients and 51% of pretreated patients 4. Current guideline recommendations on empirical antimicrobial therapy remain adequate for effective management 4.