What is the recommended treatment for epididymoorchitis?

Treatment of Epididymoorchitis

For epididymoorchitis, the recommended first-line treatment is ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days for men under 35 years with suspected STI-related infection. 1

Treatment Algorithm Based on Age and Likely Etiology

For Men Under 35 Years (Likely STI-Related)

• First-line therapy:

  • Ceftriaxone 250 mg IM single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 1, 2

• Alternative therapy (for patients with allergies to cephalosporins or tetracyclines):

  • Ofloxacin 300 mg orally twice daily for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1
  • Note: Ofloxacin is contraindicated in patients ≤17 years of age 1

For Men Over 35 Years (Likely Enteric/UTI-Related)

• First-line therapy:

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

• Alternative therapy (with rising fluoroquinolone resistance):

  • Consider broader-spectrum antibiotics based on local resistance patterns 3
  • Treatment should cover common enteric organisms, particularly E. coli 3, 4

Adjunctive Measures

• Bed rest
• Scrotal elevation
• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain management 1
• Administration of adequate fluids with doxycycline to reduce risk of esophageal irritation 2
• Doxycycline may be given with food or milk if gastric irritation occurs 2

Special Populations

• HIV-positive patients:

  • Same regimens as for HIV-negative patients
  • Higher suspicion for fungal and mycobacterial causes 1

• Elderly patients:

  • Consider STIs even in older adults with appropriate risk factors 5
  • Evaluate for underlying urinary tract abnormalities 4

Monitoring and Follow-up

• Clinical improvement should occur within 3 days of starting treatment 1
• If no improvement is seen within 48-72 hours, reevaluate diagnosis and consider surgical intervention 1, 6
• Persistent swelling or tenderness after completing antibiotics requires evaluation for:
  • Testicular cancer
  • Abscess formation
  • Tuberculous or fungal epididymitis 1

Partner Management

• Sexual partners of patients with STI-related epididymitis should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
• Both patient and partners should avoid sexual intercourse until treatment is completed and all are symptom-free 1
• Condoms provide approximately 80-90% protection against STI transmission when used correctly 1

Warning Signs Requiring Immediate Surgical Referral

• Sudden onset of severe unilateral scrotal pain
• Nausea/vomiting
• High-riding testicle
• Absent cremasteric reflex 1

Common Pitfalls and Caveats

1. Misdiagnosis of testicular torsion: This is a surgical emergency requiring intervention within 4-6 hours. Key differentiating features from epididymo-orchitis include sudden onset of pain, absence of cremasteric reflex, and high-riding testicle position 1, 4

2. Inadequate coverage of causative organisms: Treatment should be tailored to the most likely pathogens based on age and risk factors 1, 3

3. Neglecting partner treatment: This can lead to reinfection in STI-related cases 1

4. Failing to identify underlying conditions: Patients with epididymitis often have functional bladder outlet problems, BPH, urethral stricture disease, or recent urinary tract instrumentation 1, 4

5. Rising fluoroquinolone resistance: Traditional reliance on ciprofloxacin may be inadequate in areas with high resistance rates 3, 7