What is the initial treatment for a 26-year-old male with epididymitis?

Initial Treatment for Epididymitis in a 26-Year-Old Male

For a 26-year-old male with epididymitis, the recommended initial treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days. 1

Etiology and Diagnosis

In sexually active men under 35 years of age, epididymitis is most commonly caused by:

• Chlamydia trachomatis or Neisseria gonorrhoeae 1, 2
• Sexually transmitted Escherichia coli (particularly in men who are insertive partners during anal intercourse) 1

Before initiating treatment, the following diagnostic procedures should be performed:

• Gram-stained smear of urethral exudate or intraurethral swab specimen to diagnose urethritis and presumptively identify gonococcal infection 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis (either on intraurethral swab or first-void urine) 1
• Examination of first-void urine for leukocytes if urethral Gram stain is negative 1
• Syphilis serology and HIV counseling and testing 1

Treatment Regimen

Primary Treatment

• Ceftriaxone 250 mg IM in a single dose PLUS
• Doxycycline 100 mg orally twice a day for 10 days 1, 3

This combination targets both N. gonorrhoeae (ceftriaxone) and C. trachomatis (doxycycline), the most likely causative organisms in this age group 2.

Adjunctive Measures

• Bed rest
• Scrotal elevation
• Analgesics until fever and local inflammation subside 1

Follow-Up and Monitoring

• Patients should be reevaluated if symptoms do not improve within 3 days of starting treatment 1
• Persistent swelling or tenderness after completing antimicrobial therapy requires comprehensive evaluation 1
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis 1

Management of Sexual Partners

• Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
• Patients should avoid sexual intercourse until they and their partners complete therapy and are asymptomatic 1

Special Considerations

Alternative Treatment

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice a day for 10 days 1
• Levofloxacin 500 mg orally once daily for 10 days (newer alternative) 1

Hospitalization Criteria

Consider hospitalization when:

• Severe pain suggests other diagnoses (e.g., testicular torsion, testicular infarction, abscess)
• Patient is febrile
• Concerns about medication compliance exist 1

HIV Infection

• Patients with uncomplicated epididymitis who are HIV-positive should receive the same treatment regimen as HIV-negative patients 1
• Be aware that fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients 1

Clinical Pearls and Pitfalls

• Testicular torsion must be ruled out in all cases, as it is a surgical emergency that can compromise testicular viability 1
• Recent research indicates that STIs causing epididymitis are not strictly limited to patients under 35 years, so consider appropriate testing regardless of age 4
• Empiric therapy should be started before culture results are available to prevent complications such as infertility or chronic pain 1, 2
• Rising fluoroquinolone resistance in enteric organisms has been reported, making the ceftriaxone plus doxycycline combination particularly important for initial therapy 5