What is the treatment for epididymitis vs orchitis?

Treatment for Epididymitis vs Orchitis

For sexually transmitted epididymitis in men under 35 years, treatment with ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days is the recommended regimen. 1

Understanding Epididymitis and Orchitis

• Epididymitis and orchitis commonly co-exist (epididymo-orchitis), with isolated epididymitis being more common than isolated orchitis 2
• Epididymitis is characterized by inflammation of the epididymis, while orchitis refers to inflammation of the testis 3
• Men typically present with unilateral testicular pain and tenderness with swelling of the epididymis 1

Etiology and Diagnosis

Age-Based Etiology

• In men under 35 years: Most commonly caused by sexually transmitted infections (STIs) - Chlamydia trachomatis and Neisseria gonorrhoeae 4
• In men over 35 years: Usually caused by enteric bacteria (e.g., E. coli) associated with urinary tract infections 5
• In men who practice insertive anal intercourse: Enteric organisms are likely causative agents 4

Diagnostic Approach

• Evaluate for urethritis with Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field) 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
• Examination of first-void urine for leukocytes if urethral Gram stain is negative 1
• Syphilis serology and HIV counseling/testing 1

Treatment Recommendations

For Epididymitis Most Likely Caused by STIs (Men <35 years)

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 1, 6

For Epididymitis Most Likely Caused by Enteric Organisms (Men >35 years)

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

For Men Who Practice Insertive Anal Intercourse

• Ceftriaxone with 10 days of oral levofloxacin or ofloxacin to cover both STIs and enteric organisms 4

Supportive Care

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1

Follow-Up and Complications

• Reevaluation is necessary if no improvement occurs within 3 days of treatment initiation 1
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation 1
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain 4

Management of Sexual Partners

• Partners of patients with suspected or confirmed STI-related epididymitis should be referred for evaluation and treatment 1
• Contact tracing should include partners from the 60 days preceding symptom onset 1
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1

Special Considerations

HIV Infection

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

Testicular Torsion

• Must be ruled out in all cases of acute testicular pain, especially in adolescents 1
• Requires immediate specialist consultation as testicular viability may be compromised 1
• Emergency testing for torsion is indicated when pain onset is sudden and severe 1