What is the best antibiotic for a patient with testicular pain and low-grade fever?

Treatment for Testicular Pain with Low-Grade Fever

For a patient presenting with testicular pain and low-grade fever radiating from tailbone to rectal area, the best antibiotic regimen is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

Diagnostic Considerations

• The clinical presentation suggests epididymitis, which typically presents with unilateral testicular pain and tenderness, often accompanied by hydrocele and palpable swelling of the epididymis 1
• Testicular torsion must be ruled out as it is a surgical emergency, especially when pain onset is sudden and severe 1
• Evaluation should include:
  • Gram-stained smear of urethral exudate for diagnosis of urethritis and presumptive diagnosis of gonococcal infection 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

Treatment Recommendations

For patients under 35 years (likely STI-related):

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This combination targets the most common pathogens in younger men: N. gonorrhoeae and C. trachomatis 3, 4

For patients over 35 years or when enteric organisms are suspected:

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
• These regimens target enteric bacteria that commonly cause epididymitis in older men 1, 4

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days 1
• Alternative: spectinomycin 2 g IM in a single dose (for gonococcal infections in patients with severe beta-lactam allergies) 1

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation subside 1
• These supportive measures help manage symptoms while antibiotics address the underlying infection 2

Follow-Up Recommendations

• Improvement should be seen within 3 days of starting treatment 1
• Failure to improve within this timeframe requires reevaluation of both diagnosis and therapy 1
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for other conditions such as tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 1

Management of Sexual Partners

• If epididymitis is suspected to be caused by an STI, sexual partners should be referred for evaluation and treatment 1
• Partners should be evaluated if contact occurred within 60 days preceding symptom onset 1
• Patients should avoid sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic 1

Common Pitfalls and Caveats

• Misdiagnosing testicular torsion as epididymitis can lead to testicular loss; when in doubt, immediate urological consultation is warranted 1, 5
• Quinolone resistance in N. gonorrhoeae is increasing, particularly in certain geographic regions; consider local resistance patterns before prescribing fluoroquinolones 1
• Failure to treat partners can lead to reinfection and persistent symptoms 1
• Immunocompromised patients may have atypical pathogens including fungi and mycobacteria causing epididymitis 1