What is the treatment for orchitis?

Treatment for Orchitis

The treatment for orchitis should be based on the patient's age and likely causative pathogens, with men under 35 years receiving ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, while men over 35 years should receive ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Age-Based Treatment Algorithm

For Men Under 35 Years (Likely STI-Related)

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days is the recommended regimen as these patients are more likely to have sexually transmitted infections such as N. gonorrhoeae and C. trachomatis 1, 2
• Diagnostic evaluation should include Gram-stained smear of urethral exudate, culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis, and examination of first-void urine for leukocytes 1
• Chlamydia trachomatis is the most common pathogen identified in this age group (12.3%), followed by trichomonas (8.8%) and gonorrhea (3.1%) 3

For Men Over 35 Years (Likely Enteric Organisms)

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days is recommended as these patients typically have infections caused by enteric organisms, particularly E. coli 1, 4
• Urinalysis and urine culture should be performed to identify the causative organism 4
• E. coli is the most common bacteria isolated in urine cultures, followed by Streptococcus, Klebsiella, Pseudomonas, and Serratia 3
• Rising fluoroquinolone resistance in E. coli may necessitate alternative antimicrobials with adequate penetration into genital tissues 5

Supportive Measures for All Patients

• Bed rest until fever and local inflammation subside 1, 4
• Scrotal elevation to reduce swelling 1, 4
• Analgesics for pain management 1, 4
• Consider hospitalization when:
  • Patient presents with severe pain suggesting other diagnoses
  • Patient is febrile
  • There are concerns about medication compliance 1, 4

Diagnostic Considerations

• Ultrasound is recommended to confirm diagnosis and rule out testicular torsion, which is a surgical emergency requiring immediate intervention 1
• For viral orchitis, diagnosis is made through IgM serology or acute and convalescent IgG serology 1
• Viral causes include mumps virus, Coxsackie virus, rubella virus, Epstein-Barr virus, and varicella zoster virus 1, 6

Follow-Up and Management of Complications

• Reevaluate diagnosis and therapy if there is failure to improve within 3 days 1, 4
• Comprehensive evaluation is needed for persistent swelling and tenderness after completing antimicrobial therapy 1
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 1

Management of Sexual Partners

• For orchitis caused by STIs, sex 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 are cured 1

Common Pitfalls to Avoid

• Failure to distinguish orchitis from testicular torsion, which requires immediate surgical intervention 1
• Inadequate testing for STIs, particularly in younger men - studies show fewer than 3% of men with epididymo-orchitis in primary care receive testing for chlamydia 7
• Using doxycycline alone in patients >35 years, as it may not adequately cover enteric organisms 4
• Delaying empiric therapy while awaiting culture results 4
• Overlooking special considerations for immunosuppressed patients, who are more likely to have fungal or mycobacterial causes of orchitis 1