What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For epididymitis, the recommended treatment is ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days in men under 35 years with likely STI causes, or ofloxacin 300 mg orally twice daily or levofloxacin 500 mg orally once daily for 10 days in men over 35 years or those with likely enteric organism infections. 1

Etiology-Based Treatment Approach

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

• First-line treatment:
  • Ceftriaxone 250 mg IM in a single dose 2, 1
  • PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 2, 1, 3
• Rationale: Neisseria gonorrhoeae and Chlamydia trachomatis are the most common pathogens in this age group 1, 4

For patients over 35 years (likely enteric bacteria):

• First-line treatment:
  • Ofloxacin 300 mg orally twice daily for 10 days 2, 1
  • OR
  • Levofloxacin 500 mg orally once daily for 10 days 2, 1
• Rationale: Enteric bacteria (especially E. coli) are the predominant cause in this age group, often associated with bladder outlet problems 1, 5

For patients with allergies to cephalosporins/tetracyclines:

• Use fluoroquinolone regimens as listed above 2, 1

Adjunctive Measures

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

• Bed rest until fever and local inflammation subside 2, 1
• Scrotal elevation to reduce edema and pain 2, 1
• Analgesics/NSAIDs for pain management 1

Treatment Monitoring and Follow-up

• Patients should show clinical improvement within 3 days of starting treatment 2, 1
• Warning sign: Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 2, 1
• Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, or fungal epididymitis) 2, 1

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 2, 1
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 2, 1

Special Considerations

HIV-Infected Patients

• Same treatment regimen as HIV-negative patients 2, 1
• Higher suspicion for fungal and mycobacterial causes 2, 1

Antibiotic Resistance Concerns

• Rising resistance to fluoroquinolones in E. coli isolates is a growing concern for treating epididymitis in older men 5
• Studies show ciprofloxacin remains more effective than alternatives like pivampicillin for men over 40 years 6

Surgical Intervention

• Conservative management with antibiotics is successful in most cases 7
• Surgery (typically organ-sparing) may be required in cases with:
  • No clinical improvement after 48-72 hours of antibiotics 7
  • Presence of abscess formation 7
  • Severe cases with testicular ischemia 1

Potential Complications

If left untreated or inadequately treated, epididymitis can lead to:

• Abscess formation
• Testicular ischemia
• Infertility
• Chronic scrotal pain 1

Remember that proper diagnosis is crucial before starting treatment, as testicular torsion (which presents similarly) is a surgical emergency requiring immediate intervention rather than antibiotics 1.