What is the treatment for epididymitis?

Treatment of Epididymitis

The first-line treatment for epididymitis is ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10-21 days, with treatment duration varying based on patient age and suspected pathogen. 1

Treatment Algorithm Based on Age and Risk Factors

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

For Men Over 35 Years (Likely Enteric Organisms)

• First-line therapy:
  • Levofloxacin 500 mg orally once daily for 10 days OR
  • Ofloxacin 300 mg orally twice daily for 10 days 1

For Men Who Practice Insertive Anal Intercourse

• First-line therapy:
  • Ceftriaxone 250 mg IM single dose PLUS
  • Levofloxacin 500 mg orally once daily for 10 days OR
  • Ofloxacin 300 mg orally twice daily for 10 days 1, 3

For Patients with Allergies to Cephalosporins or Tetracyclines

• Alternative therapy:
  • 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

Supportive Measures

• Bed rest
• Scrotal elevation
• NSAIDs for pain management 1

Monitoring and Follow-up

• Clinical improvement should occur within 3 days of starting treatment
• If no improvement is seen, reevaluate diagnosis and therapy 1
• Consider scrotal ultrasound with Doppler to rule out testicular torsion or other conditions 1

Partner Management

• Sexual partners of patients with STI-related epididymitis should be evaluated and treated 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 1

Important Considerations and Pitfalls

Diagnostic Pitfalls

• Critical: Epididymitis must be distinguished from testicular torsion, which requires immediate surgical intervention
• Key differentiating features:

  Feature	Epididymitis	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

Treatment Pitfalls

1. Inadequate evaluation: Studies show less than 35% of patients receive appropriate workup per CDC guidelines 4
2. Inappropriate antibiotic selection: Many patients receive antibiotics not in accordance with guidelines 4
3. Fluoroquinolone resistance: Rising resistance to ciprofloxacin in E. coli isolates necessitates adherence to current guidelines 5
4. Neglecting partner treatment: Can lead to reinfection in STI-related cases 1

Complications if Untreated

• Abscess formation
• Testicular ischemia
• Infertility
• Chronic scrotal pain 1, 3

Remember that clinical improvement should be evident within 3 days of starting appropriate therapy. If symptoms persist or worsen, reevaluation of diagnosis and treatment is necessary.