First-Line Treatment for Orchitis
The first-line treatment for orchitis depends on the suspected etiology, with antimicrobial therapy consisting of ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days being recommended for cases likely caused by sexually transmitted infections in men under 35 years. 1
Treatment Algorithm Based on Patient Age and Likely Etiology
For patients under 35 years (likely STI-related orchitis):
First-line treatment:
This combination targets both N. gonorrhoeae (ceftriaxone) and C. trachomatis (doxycycline), which are the most common pathogens in this age group 4
For patients over 35 years or with suspected enteric organisms:
First-line treatment:
These regimens target enteric organisms commonly causing orchitis in older men, often associated with urinary tract abnormalities 5, 6
For patients with allergies to cephalosporins or tetracyclines:
- Use fluoroquinolones as listed above, but be aware of increasing resistance patterns 6
Supportive Measures (for all patients)
- Bed rest until fever and local inflammation subside
- Scrotal elevation
- Analgesics/NSAIDs for pain management 2, 1
Key Diagnostic Considerations
Before initiating treatment, it's crucial to differentiate orchitis from testicular torsion, which is a surgical emergency:
| Feature | Orchitis/Epididymo-orchitis | Testicular Torsion |
|---|---|---|
| Onset | Gradual | Sudden |
| Pain relief with elevation | Yes (Prehn sign) | No |
| Cremasteric reflex | Present | Absent |
| Testicular position | Normal | High-riding |
| Doppler ultrasound | Increased blood flow | Decreased/absent blood flow |
Follow-Up and Monitoring
- Clinical improvement should occur within 3 days of starting treatment
- If no improvement is seen within this timeframe, reevaluation of diagnosis and therapy is necessary 2, 1
- Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for other conditions (tumor, abscess, testicular cancer, TB, fungal infection) 2
Partner Management (for STI-related cases)
- Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
- Both patient and partners should avoid sexual intercourse until treatment is completed and all are symptom-free 2, 1
Special Considerations
- For viral orchitis (e.g., mumps): Supportive care is the mainstay as antibiotics are ineffective 7
- For HIV-positive patients: Use the same regimens as for HIV-negative patients, but maintain higher suspicion for fungal and mycobacterial causes 2, 1
- For mumps orchitis: Treatment is primarily supportive with NSAIDs, as this is a viral condition not responsive to antibiotics 7
Common Pitfalls to Avoid
- Failing to rule out testicular torsion before initiating antibiotic therapy
- Not obtaining appropriate diagnostic tests (urethral swab/urine for STI testing, urinalysis)
- Neglecting partner treatment in STI-related cases
- Continuing the same antibiotic regimen when no improvement is seen after 3 days
- Using fluoroquinolones in patients ≤17 years of age (contraindicated) 1