What is the treatment plan for epididymitis?

Treatment Plan for Epididymitis

The treatment of epididymitis requires targeted antimicrobial therapy based on patient age and likely causative organisms, with ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 10 days being the recommended regimen for sexually transmitted infections in men under 35 years. 1

Diagnosis and Evaluation

Before initiating treatment, proper evaluation is essential:

• Perform a Gram-stained smear of urethral exudate or intraurethral swab specimen to diagnose urethritis (≥5 polymorphonuclear leukocytes per oil immersion field) and for presumptive diagnosis of gonococcal infection 1
• Obtain culture of urethral exudate or intraurethral swab specimen, or nucleic acid amplification test (either on intraurethral swab or first-void urine) for N. gonorrhoeae and C. trachomatis 1
• Examine first-void uncentrifuged urine for leukocytes if the urethral Gram stain is negative, including culture and Gram-stained smear 1
• Consider syphilis serology and HIV counseling and testing 1

Treatment Regimens Based on Patient Age and Risk Factors

For men <35 years or sexually transmitted epididymitis:

• First-line treatment: Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2
• This regimen targets the most common causative organisms in this age group: C. trachomatis and N. gonorrhoeae 3

For men >35 years or epididymitis likely caused by enteric organisms:

• First-line treatment: Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 1
• These regimens target enteric organisms commonly associated with urinary tract infections in older men 4

For men who practice insertive anal intercourse:

• Consider treatment for both STIs and enteric organisms: Ceftriaxone with 10 days of oral levofloxacin or ofloxacin 3

For patients allergic to cephalosporins and/or tetracyclines:

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

Adjunctive Measures

• Bed rest and scrotal elevation until fever and local inflammation subside 1
• Analgesics for pain management 1
• Consider hospitalization for patients with severe pain suggesting alternative diagnoses (torsion, testicular infarction, abscess), high fever, or likely non-compliance with treatment 1

Follow-Up and Management

• Reevaluate if no improvement within 3 days, as this requires reassessment of both diagnosis and therapy 1
• Persistent swelling and tenderness after completing antimicrobial therapy should be comprehensively evaluated for other conditions (tumor, abscess, infarction, testicular cancer, tuberculous or fungal epididymitis) 1
• Instruct patients to avoid sexual intercourse until they and their partners are cured (therapy completed and symptoms resolved) 1

Management of Sexual Partners

• For epididymitis caused by N. gonorrhoeae or C. trachomatis, refer sexual partners for evaluation and treatment 1
• Partners should be referred if contact occurred within 60 days preceding symptom onset 1

Special Considerations

HIV Infection

• Patients with uncomplicated epididymitis who are HIV-positive should receive the same treatment regimen as HIV-negative patients 1
• Be aware that fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients 1

Common Pitfalls to Avoid

• Failing to distinguish epididymitis from testicular torsion, which is a surgical emergency requiring immediate specialist consultation 1
• Not considering age-specific pathogens when selecting antimicrobial therapy 3, 5
• Overlooking STIs in men over 35 years old (STIs are not limited to younger patients) 5
• Discontinuing treatment prematurely if symptoms improve rapidly 1
• Neglecting partner notification and treatment for sexually transmitted cases 1