What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For epididymitis, the recommended treatment is ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for 10 days for sexually transmitted cases in men under 35 years, while ofloxacin 300 mg orally twice a day for 10 days is recommended for cases likely caused by enteric organisms in men over 35 years. 1

Treatment Algorithm Based on Age and Risk Factors

For men under 35 years (likely sexually transmitted):

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days 2, 1
• This regimen targets the most common pathogens in this age group: Neisseria gonorrhoeae and Chlamydia trachomatis 3
• Studies confirm that C. trachomatis accounts for approximately two-thirds of "idiopathic epididymitis" in young men 4, 5

For men over 35 years (likely enteric organisms):

• Ofloxacin 300 mg orally twice a day for 10 days 2, 1
• Alternative: Levofloxacin 500 mg orally once daily for 10 days 1
• Enteric bacteria, particularly E. coli, are the predominant pathogens in this age group, typically from reflux of urine into ejaculatory ducts secondary to bladder outlet obstruction 3, 4

For men who practice insertive anal intercourse:

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

Supportive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2, 1
• These adjunctive measures help reduce pain and swelling while antibiotics address the underlying infection 2

Follow-Up and Monitoring

• Reevaluate if no improvement within 3 days, as this may indicate incorrect diagnosis or inadequate therapy 2, 1
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, tuberculous or fungal epididymitis) 2, 1

Management of Sexual Partners

• For sexually transmitted epididymitis, refer sex partners for evaluation and treatment if contact occurred within 60 days of symptom onset 2, 1
• Advise patients to avoid sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic 2
• Female partners of men with C. trachomatis epididymitis may have asymptomatic infection or pelvic inflammatory disease 4, 5

Special Considerations

• HIV-positive patients with uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients 2, 1
• Be aware that fungi and mycobacteria are more common causes of epididymitis in immunosuppressed patients 2, 1
• Consider hospitalization if severe pain suggests other diagnoses (like testicular torsion) or if the patient is febrile 1

Diagnostic Evaluation

• Gram-stained smear of urethral exudate 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, 1
• Urinary tract infection should be ruled out with culture and Gram-stained smear of uncentrifuged urine 2
• Syphilis serology and HIV testing 2, 1

Common Pitfalls

• Failing to distinguish epididymitis from testicular torsion, which is a surgical emergency 2, 3
• Not considering age-appropriate pathogens when selecting antibiotics 3
• Inadequate treatment duration leading to chronic epididymitis or infertility 3
• Neglecting to treat sexual partners in cases of sexually transmitted epididymitis 2, 1
• Missing underlying urinary tract abnormalities in older men 3