What is the treatment for epididymitis?

Treatment for Epididymitis

The recommended treatment for epididymitis depends on the likely causative organism, with ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days being the standard regimen for sexually transmitted infections in men under 35 years. 1, 2

Treatment Based on Likely Etiology

For epididymitis likely caused by gonococcal or chlamydial infection (typically in men <35 years):

• Ceftriaxone 250 mg IM in a single dose, PLUS doxycycline 100 mg orally twice a day for 10 days 1, 2
• This combination provides coverage for both Neisseria gonorrhoeae and Chlamydia trachomatis, which are the most common pathogens in sexually active younger men 3

For epididymitis likely caused by enteric organisms (typically in men >35 years) or for patients allergic to cephalosporins/tetracyclines:

• Ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2
• Enteric bacteria are more common in older men, often related to bladder outlet obstruction 3, 4

For men who practice insertive anal intercourse:

• Consider coverage for enteric organisms in addition to STIs 3
• Ceftriaxone with 10 days of oral levofloxacin or ofloxacin is recommended 3

Supportive Measures

• Bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation subside 1, 2
• These adjunctive measures help manage symptoms and promote recovery 1

Follow-Up and Monitoring

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

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-Infected Patients

• 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

Diagnostic Considerations

• Testicular torsion must be ruled out in all cases of acute testicular pain, especially in adolescents 1, 2
• Emergency testing for torsion is indicated when pain onset is sudden and severe 2
• Diagnostic evaluation should include Gram-stained smear of urethral exudate, culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis, and examination of first-void urine for leukocytes 1

Antimicrobial Resistance Concerns

• Rising resistance to fluoroquinolones in E. coli isolates means alternative antimicrobials may be needed in some cases 4
• Recent studies show that even in antimicrobially pretreated patients, epididymitis is mainly of bacterial origin 5

Treatment Efficacy

• Modern diagnostic techniques have identified causative pathogens in up to 88% of antibiotic-naive patients 5
• With appropriate antimicrobial therapy, most cases can be managed conservatively without surgical intervention 5