What is the treatment for orchitis?

Treatment for Orchitis

The treatment for orchitis depends on the underlying cause, with antibiotics being the primary therapy for bacterial orchitis, specifically doxycycline 100 mg orally twice daily for 10 days for sexually transmitted infections in men under 35, and fluoroquinolones for enteric organisms in older men. 1, 2

Diagnosis and Evaluation

• Orchitis often co-exists with epididymitis (epididymo-orchitis), presenting with testicular pain and swelling 3
• Diagnostic evaluation should include:
  • Gram-stained smear of urethral exudate for diagnosis of urethritis 1
  • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
  • Examination of first-void urine for leukocytes 1
  • Ultrasound to confirm diagnosis and rule out testicular torsion, which is a surgical emergency 1

Treatment Based on Age and Likely Pathogens

For men under 35 years (likely sexually transmitted infections):

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice daily for 10 days 1, 2
• C. trachomatis is the most common pathogen (12.3%) in this age group, followed by N. gonorrhoeae (3.1%) 4

For men over 35 years (likely enteric organisms):

• Ofloxacin 300 mg orally twice daily for 10 days OR
• Levofloxacin 500 mg orally once daily for 10 days 1
• E. coli is the most common pathogen in this age group 5, 4

For acute epididymo-orchitis caused by N. gonorrhoeae or C. trachomatis:

• Doxycycline 100 mg orally twice daily for at least 10 days 2

Supportive Measures

• Bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation subside 1
• Consider hospitalization when:
  • Severe pain suggests other diagnoses (torsion, testicular infarction, abscess)
  • Patient is febrile
  • Patient might be non-compliant with antimicrobial regimen 1

Follow-Up and Management of Complications

• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Persistent swelling and tenderness after completing antimicrobial therapy should be comprehensively evaluated 1
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1

Management of Sexual Partners

• For orchitis caused by STIs, sex partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
• Patients should avoid sexual intercourse until they and their partners are cured (therapy completed and no symptoms) 1

Special Considerations

• Viral orchitis (most commonly from mumps) is diagnosed through IgM serology or acute and convalescent IgG serology 1
• Other viral causes include Coxsackie virus, rubella virus, Epstein-Barr virus, and varicella zoster virus 1
• Systemic fungal diseases and tuberculosis can also involve the testis 1
• Rising resistance to fluoroquinolones in E. coli isolates necessitates consideration of alternative antimicrobials with adequate penetration into genital tissues 5

Pitfalls and Caveats

• Testicular torsion must be ruled out in all cases of acute testicular pain, as it is a surgical emergency requiring intervention within 4-6 hours 3
• Only 50.1% of men diagnosed with epididymitis, orchitis, or both are tested for gonorrhea and chlamydia, highlighting the importance of appropriate testing 4
• Immunosuppressed patients are more likely to have fungal or mycobacterial causes of orchitis 1