What is the treatment for epididymitis (inflammation of the epididymis)?

Treatment for Epididymitis

For epididymitis, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days in men under 35 years, or ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days in men over 35 years. 1, 2

Treatment Based on Age and Likely Pathogens

For patients under 35 years (likely sexually transmitted infection):

• Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days, targeting Neisseria gonorrhoeae and Chlamydia trachomatis 3, 1
• This regimen is effective against the most common pathogens in this age group, with studies showing high rates of pathogen eradication 4

For patients over 35 years or with risk factors for enteric organisms:

• Ofloxacin 300 mg orally twice a day for 10 days OR levofloxacin 500 mg orally once daily for 10 days 3, 1
• These regimens target enteric organisms, particularly E. coli, which are more common in older men 4, 5
• Risk factors for enteric organisms include 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 due to the likelihood of enteric organisms 4

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 3, 1
• These measures help reduce pain and swelling while antibiotics address the underlying infection 1
• Administration of adequate fluids with doxycycline is recommended to reduce the risk of esophageal irritation 6

Follow-Up and Monitoring

• 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, 2
• Consider hospitalization for patients with severe pain suggesting alternative diagnoses, fever, or likely non-compliance with treatment 1
• Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for alternative diagnoses 3, 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

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
• Modern diagnostic techniques have improved pathogen detection, with studies showing bacterial causes in up to 88% of antibiotic-naive patients 5

Important Caveats and Pitfalls

• 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 3, 1
• Emergency testing for torsion is indicated when pain onset is sudden and severe 2
• STIs are not limited to patients aged <35 years; comprehensive testing is warranted regardless of age 5
• Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis 3, 2