What is the treatment for epididymitis in a 15-year-old male?

Treatment for Epididymitis in a 15-Year-Old Male

The recommended treatment for epididymitis in a 15-year-old male is ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 10 days, along with supportive measures including bed rest and scrotal elevation until fever and local inflammation subside. 1, 2

Diagnostic Considerations

Before initiating treatment, proper diagnosis is essential to rule out testicular torsion, which is a surgical emergency more common in adolescents:

• Epididymitis typically presents with gradual onset of unilateral testicular pain and tenderness
• Palpable swelling of the epididymis is usually present
• Presence of Prehn sign (pain relief with scrotal elevation) suggests epididymitis
• Normal testicular position and present cremasteric reflex favor epididymitis over torsion 1

Diagnostic evaluation should include:

• Gram-stained smear of urethral exudate for N. gonorrhoeae and evidence of urethritis
• Culture of urethral exudate for N. gonorrhoeae
• Testing for C. trachomatis
• Urinalysis and urine culture 2
• Scrotal ultrasound with Doppler to rule out torsion 1

Treatment Regimen

First-Line Antimicrobial Therapy

In adolescents, epididymitis is most commonly caused by sexually transmitted infections, particularly N. gonorrhoeae and C. trachomatis 2, 3:

• Ceftriaxone 250 mg IM in a single dose (targets N. gonorrhoeae)
• PLUS
• Doxycycline 100 mg orally twice daily for 10 days (targets C. trachomatis) 2, 1, 4

The FDA-approved dosing for doxycycline in acute epididymitis caused by C. trachomatis is 100 mg orally twice daily for at least 10 days 4.

Supportive Measures

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

• Bed rest until fever and local inflammation subside
• Scrotal elevation to reduce edema and pain
• Non-steroidal anti-inflammatory drugs for pain management 2, 1

Follow-Up and Warning Signs

• Clinical improvement should occur within 3 days of starting treatment
• Failure to improve within 3 days requires re-evaluation of both diagnosis and therapy, and consideration of hospitalization 2, 1
• Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for other conditions, such as testicular cancer, tuberculosis, or fungal epididymitis 2

Management of Sexual Partners

For adolescents with epididymitis likely caused by STIs:

• Sexual partners should be referred for evaluation and treatment if contact occurred within 30 days of symptom onset
• Both patient and partners should avoid sexual intercourse until treatment is completed and all are symptom-free 2, 1

Important Considerations for Adolescents

• Ofloxacin, which is sometimes used as an alternative treatment in adults, is contraindicated in patients ≤17 years of age 2
• Doxycycline should be administered with adequate amounts of fluid to reduce the risk of esophageal irritation 4
• If gastric irritation occurs, doxycycline can be given with food or milk without significantly affecting absorption 4

Common Pitfalls to Avoid

1. Misdiagnosis of testicular torsion as epididymitis - torsion requires immediate surgical intervention
2. Inadequate follow-up - failure to improve within 3 days requires prompt reassessment
3. Incomplete treatment - full course of antibiotics must be completed even if symptoms improve
4. Neglecting partner treatment - essential to prevent reinfection and further transmission

By following this evidence-based approach, epididymitis in adolescents can be effectively treated, preventing complications such as infertility and chronic scrotal pain 3.