What is the recommended treatment for acute epididymitis?

Treatment of Acute Epididymitis

For acute epididymitis, the recommended treatment 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 cases in men under 35 years. 1, 2

Etiology and Treatment Algorithm

For patients likely infected with sexually transmitted organisms (typically men <35 years):

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This regimen targets the most common pathogens in this age group: Neisseria gonorrhoeae and Chlamydia trachomatis 3
• Studies show these organisms are present in up to 78% of epididymitis cases in young men 4

For patients likely infected with enteric organisms (typically men >35 years or insertive anal intercourse):

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2, 3
• Enteric bacteria are more common in older men due to reflux of urine into ejaculatory ducts secondary to bladder outlet obstruction 3

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days 1

Adjunctive Measures

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

Follow-Up and Monitoring

• Reevaluation is necessary if no improvement occurs within 3 days of treatment initiation 1
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation 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 Infection

• 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 causes in immunosuppressed patients 1

Diagnostic Pearls

• Testicular torsion must be ruled out in all cases of acute testicular pain, especially in adolescents 1, 2
• Emergency consultation is indicated when pain onset is sudden and severe, as testicular viability may be compromised 1
• Modern diagnostic techniques have improved pathogen detection rates, with 16S rDNA analysis increasing detection by approximately 10% 5

Treatment Efficacy

• Recent studies show that even in antimicrobially pretreated patients, epididymitis is mainly of bacterial origin 5
• Current guideline recommendations on empirical antimicrobial therapy remain adequate with susceptibility to fluoroquinolones and group 3 cephalosporins in >85% of cases in antibiotic-naïve patients 5
• Viral epididymitis is rare, with enteroviruses found in only about 1% of cases 5