What is the treatment for epididymitis?

Treatment of Epididymitis

For epididymitis most likely caused by gonococcal or chlamydial infection (sexually active men <35 years), the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days. 1

Etiology-Based Treatment Approach

Treatment of epididymitis depends on the likely causative organisms, which vary based on patient age and risk factors:

• Men <35 years (sexually active): Most commonly caused by Neisseria gonorrhoeae and/or Chlamydia trachomatis 1, 2

  • Treatment: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1

• Men who practice insertive anal intercourse: Consider enteric organisms in addition to STIs 2

  • Treatment: Ceftriaxone 250 mg IM single dose PLUS either levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1

• Men >35 years OR with urinary tract abnormalities: Usually caused by enteric bacteria 2, 3

  • Treatment: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1

• Patients allergic to cephalosporins and/or tetracyclines:

  • Treatment: Ofloxacin 300 mg orally twice daily for 10 days 1

Supportive Measures

As adjunctive therapy, the following are recommended until fever and local inflammation subside:

• Bed rest 1
• Scrotal elevation 1
• Analgesics for pain management 1

Follow-Up Recommendations

• 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
• The differential diagnosis for persistent symptoms includes: tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1

Management of Sexual Partners

• For epididymitis caused by STIs, 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 both they and their partners complete treatment and are asymptomatic 1

Special Considerations

• HIV-infected patients: Should receive the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 1
• Caution: Fungi and mycobacteria are more likely causes in immunosuppressed patients 1
• Rising fluoroquinolone resistance: Increasing resistance to ciprofloxacin in E. coli isolates may necessitate alternative antimicrobials for treating epididymitis caused by enteric organisms 3

Common Pitfalls and Caveats

• Misdiagnosis: Testicular torsion, a surgical emergency, should be considered in all cases of acute scrotal pain, especially in adolescents 1
• Delayed treatment: Untreated acute epididymitis can lead to infertility and chronic scrotal pain 2
• Inadequate diagnostic workup: Proper evaluation should include urethral Gram stain, culture or nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis, and examination of first-void urine 1
• Failure to treat partners: Not treating sexual partners can lead to reinfection 1