What is the initial treatment for epididymitis?

Initial Treatment for Epididymitis

The initial treatment for epididymitis is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days for patients under 35 years, while patients over 35 years should receive ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1, 2

Treatment Based on Age and Likely Pathogens

For Patients Under 35 Years (Sexually Transmitted Infections)

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days is the recommended regimen, targeting Chlamydia trachomatis and Neisseria gonorrhoeae 3, 1
• This combination therapy is particularly important as sexually transmitted infections are the most common cause in this age group 4
• The FDA-approved dosage for doxycycline in acute epididymitis caused by C. trachomatis is 100 mg orally twice a day for at least 10 days 5

For Patients Over 35 Years (Enteric Organisms)

• Ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days is recommended 1, 2
• These regimens target enteric organisms (particularly E. coli) which are more common in older men 4
• This treatment is also appropriate for patients with recent urinary tract instrumentation/surgery or anatomical abnormalities 1

For Men Who Practice Insertive Anal Intercourse

• Ceftriaxone with 10 days of oral levofloxacin or ofloxacin is recommended to cover both STIs and enteric organisms 4

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 3, 1
• These supportive measures help reduce pain and swelling while antibiotics address the underlying infection 1

Follow-Up Recommendations

• Improvement should be seen within 3 days of starting treatment 3, 1
• Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Consider alternative diagnoses if symptoms persist, including testicular torsion (surgical emergency), tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1, 2

Management of Sexual Partners

• For epididymitis caused by STIs, sex partners should be referred for evaluation and treatment if contact occurred within 60 days of symptom onset 3, 1
• Patients should avoid sexual intercourse until both they and their partners complete treatment and are symptom-free 1, 2

Common Pitfalls and Caveats

• Testicular torsion must be ruled out in all cases of acute testicular pain, especially in adolescents, as it is a surgical emergency requiring immediate intervention 1, 2
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain 4
• Even with appropriate diagnostic techniques, approximately 30% of cases may have unknown etiology 6
• Recent studies show that bacterial pathogens can be identified in up to 88% of antibiotic-naive patients using comprehensive testing including PCR and 16S rDNA analysis 6

Special Considerations

• HIV-infected patients with uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients 3, 1
• Fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients 3, 2
• In children younger than 14 years, reflux of urine into the ejaculatory ducts is considered the most common cause of epididymitis 4