What is the recommended treatment for epididymoorchitis?

Diagnosis and Treatment of Epididymoorchitis

The recommended treatment for epididymoorchitis depends on patient age and likely causative organisms, with ceftriaxone 250 mg IM single dose plus doxycycline 100 mg orally twice daily for 10 days for men under 35 years, and fluoroquinolones (ofloxacin or levofloxacin) for men over 35 years. 1

Diagnostic Approach

• Epididymoorchitis typically presents with unilateral testicular pain and tenderness, with palpable swelling of the epididymis and often hydrocele 2
• Testicular torsion must be ruled out in all cases, especially in adolescents and those with sudden onset of severe pain without evidence of inflammation 2
• Diagnostic evaluation should include:
  • Gram-stained smear of urethral exudate or intraurethral swab for diagnosis of urethritis 2
  • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 2, 1
  • Examination of first-void urine for leukocytes if urethral Gram stain is negative 2
  • Syphilis serology and HIV counseling/testing 2

Treatment Algorithm

For Men Under 35 Years (Likely STI-Related)

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

For Men Over 35 Years (Likely Enteric Organisms)

• First-line treatment: Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 2, 1
• These regimens are more effective against enteric organisms commonly causing infection in older men 1
• Note: Rising fluoroquinolone resistance in E. coli may necessitate alternative antibiotics in some regions 4

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2, 1
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 2, 1

Special Considerations

Management of Sexual Partners

• Partners of patients with epididymoorchitis caused by STIs should be evaluated and treated 2
• Referral is indicated if contact occurred within 60 days prior to symptom onset 1
• Patients should avoid sexual intercourse until they and their partners complete treatment and are asymptomatic 2

HIV-Infected Patients

• Patients with HIV and uncomplicated epididymoorchitis should receive the same treatment regimen as HIV-negative patients 2, 1
• Immunosuppressed patients are more susceptible to fungal and mycobacterial infections 1

Hospitalization Criteria

• Consider inpatient management for:
  • Severe pain suggesting alternative diagnoses 2
  • Febrile patients 2
  • Concerns about medication adherence 2, 1

Staging and Treatment Response

• Patients can be classified into stages based on clinical findings, which helps guide treatment decisions 5:
  • Stage 1: Palpable difference between epididymis and testis, no hydrocele or abscess - typically responds well to antibiotics alone 5
  • Stage 2: Palpable difference between epididymis and testis with hydrocele and possibly small abscesses - may require surgical intervention in ~15% of cases 5
  • Stage 3: No palpable differentiation between epididymis and testis, with hydrocele and possible abscesses - often requires surgical intervention 5

Complications and Follow-up

• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation 2
• Differential diagnosis for non-resolving cases includes tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 2, 6
• Approximately 40% of patients may develop post-inflammatory subfertility 6
• Only about 10% of patients experience relapse, which should prompt evaluation for subvesical obstruction 6