Treatment of Epididymitis
For sexually active men under 35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover gonorrhea and chlamydia. 1
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
- Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 2, 1, 3
- This combination targets Neisseria gonorrhoeae and Chlamydia trachomatis, which account for the majority of cases in this age group (78% in one study, with gonorrhea in 57% and chlamydia in 34%) 4
- Chlamydia causes two-thirds of previously "idiopathic" epididymitis cases in young men and can lead to oligospermia if untreated 5
Men Who Practice Insertive Anal Intercourse
- Modified regimen: 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 2, 1
- The fluoroquinolone component covers enteric organisms in addition to STIs 1
- Caveat: Rising fluoroquinolone resistance in E. coli isolates is a growing concern, though these remain guideline-recommended agents 6
Men Over 35 Years (Enteric Organism Etiology)
- Fluoroquinolone monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2, 1
- Enteric bacteria, particularly E. coli, predominate in this age group (30% versus 3% in younger men), typically from urinary reflux into ejaculatory ducts secondary to bladder outlet obstruction 5, 4
Patients with Cephalosporin or Tetracycline Allergies
Essential Supportive Measures
- Adjunctive therapy: Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2, 1
- These measures are recommended as standard care alongside antimicrobials 1
Critical Follow-Up Protocol
- 3-day reassessment: Reevaluate both diagnosis and therapy if no improvement within 3 days of treatment initiation 2, 1
- Persistent symptoms after treatment completion require comprehensive evaluation for tumor, abscess, testicular infarction, testicular cancer, tuberculosis, or fungal epididymitis 2, 1
- The differential diagnosis broadens significantly when standard antimicrobial therapy fails 1
Sexual Partner Management
- Partner notification: All sexual contacts within 60 days preceding symptom onset must be evaluated and treated for STI-related epididymitis 2, 1
- Sexual abstinence: Required until both patient and partner(s) complete therapy and are asymptomatic 2, 1
- Female partners of men with chlamydial epididymitis have high rates of infection (67% with antibodies, with some having pelvic inflammatory disease) 5
- Common pitfall: Failure to treat partners leads to reinfection and continued transmission 1
Special Populations
HIV-Infected Patients
- Same treatment regimen as HIV-negative patients for uncomplicated epididymitis 2, 1
- However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 2, 1
Pediatric Patients (Under 14 Years)
- Urinary reflux into ejaculatory ducts is the most common cause, not STIs 7
- Treatment should target enteric organisms rather than sexually transmitted pathogens 7
Critical Diagnostic Considerations
- Rule out testicular torsion first, especially in adolescents—this is a surgical emergency that can mimic epididymitis 1
- Perform urethral Gram stain, culture or nucleic acid amplification testing for gonorrhea and chlamydia, and examine first-void urine 1
- In busy clinical settings with limited resources, endourethral Gram stain showing inflammatory cells with gram-negative diplococci indicates treatment for both gonorrhea and chlamydia; inflammatory cells without diplococci suggests chlamydia alone 4