What is the recommended treatment for epididymitis with symptoms of a swollen, tender, and warm scrotum?

Treatment for Epididymitis with Swollen, Tender, and Warm Scrotum

For epididymitis with symptoms of a swollen, tender, and warm scrotum, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days for patients under 35 years, or a fluoroquinolone (ofloxacin 300 mg orally twice daily or levofloxacin 500 mg orally once daily for 10 days) for patients over 35 years or those with suspected enteric organisms. 1

Antimicrobial Therapy Based on Age and Risk Factors

For patients under 35 years (likely sexually transmitted pathogens):

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days 1
• This combination targets the most common pathogens in this age group: Chlamydia trachomatis and Neisseria gonorrhoeae 2, 3
• Empiric therapy should be initiated before culture results are available to prevent complications such as infertility or chronic pain 1

For patients over 35 years or with risk factors for enteric organisms:

• Ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
• Enteric organisms (particularly E. coli) are more common in men over 35 years, those with recent urinary tract instrumentation/surgery, or anatomical abnormalities 1, 3
• Note: Rising fluoroquinolone resistance in enteric organisms may necessitate alternative treatments in some cases 4

For men who practice insertive anal intercourse:

• Consider treatment for both STI pathogens and enteric organisms 1, 3
• Ceftriaxone 250 mg IM in a single dose PLUS levofloxacin or ofloxacin for 10 days 3

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1
• These supportive measures help reduce pain and swelling while antibiotics address the underlying infection 1

Follow-Up Recommendations

• Improvement should be seen within 3 days of starting treatment 1
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Consider hospitalization for patients with severe pain suggesting alternative diagnoses (torsion, testicular infarction, abscess), fever, or likely non-compliance with treatment 1

Management of Sex Partners

• For epididymitis caused by STIs, sex partners should be referred for evaluation and treatment if contact occurred within 60 days of symptom onset 1
• Patients should avoid sexual intercourse until both they and their partners complete treatment and are symptom-free 1

Special Considerations

• HIV-infected patients with uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients 1
• Be aware that fungi and mycobacteria are more likely causes of epididymitis in immunosuppressed patients 1
• Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for alternative diagnoses including tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 1

Common Pitfalls and Caveats

• Don't confuse epididymitis with testicular torsion, which is a surgical emergency requiring immediate intervention 1
• Testicular torsion is more common in adolescents and typically presents with sudden onset of severe pain without evidence of infection 1
• If diagnosis is questionable, consult a specialist immediately as testicular viability may be compromised 1
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making prompt recognition and appropriate therapy essential 3