What is the treatment for epididymitis?

Treatment of Epididymitis

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years or those with enteric risk factors, use levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Pathogens)

• Primary regimen: Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2
• This targets Chlamydia trachomatis and Neisseria gonorrhoeae, which are the predominant pathogens in this age group 2, 4
• Recent molecular diagnostic studies confirm that STIs are not strictly limited to patients under 35 years, so consider this regimen in older sexually active men with risk factors 5

Men Over 35 Years (Enteric Organisms)

• Primary regimen: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
• Enteric organisms, particularly E. coli, predominate in this age group, especially with bladder outlet obstruction, recent urinary instrumentation, or anatomical abnormalities 2, 4
• Fluoroquinolone monotherapy is sufficient as enteric bacteria are susceptible in >85% of antibiotic-naive cases 5

Special Population: Men Who Practice Insertive Anal Intercourse

• Modified regimen: Ceftriaxone 250 mg IM once PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2, 4
• This covers both STI pathogens and enteric organisms that may be causative in this population 2, 4

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 3, 1, 2
• These measures reduce pain and swelling while antibiotics address the underlying infection 2
• Adequate fluid intake with oral medications reduces risk of esophageal irritation 6

Critical Follow-Up Timeline

• Reassess within 3 days if no clinical improvement occurs 3, 1, 2
• Failure to improve requires reevaluation of both diagnosis and therapy 1, 2
• Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculous or fungal epididymitis 3, 1, 2

Management of Sexual Partners

• Refer all sexual partners from the preceding 60 days for evaluation and treatment when STI etiology is known or suspected 3, 1, 2
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are symptom-free 3, 2
• Untreated partners perpetuate transmission and risk reinfection 4

Hospitalization Criteria

Consider admission for patients with: 1, 2

• Severe pain suggesting testicular torsion, infarction, or abscess
• Fever indicating systemic involvement
• Anticipated noncompliance with oral antimicrobial regimen

Special Considerations

HIV-Infected Patients

• Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 3, 1, 2
• However, maintain higher suspicion for fungal and mycobacterial causes in immunocompromised patients 3, 1, 2

Patients with Antibiotic Pretreatment

• Pathogen detection drops from 88% to 51% in pretreated patients 5
• Bacterial susceptibility to fluoroquinolones decreases from >85% to 42% in pretreated cases 5
• Consider broader coverage or culture-directed therapy in this population 5

Common Pitfalls to Avoid

• Do not miss testicular torsion: This surgical emergency presents with sudden onset of severe pain, is more common in adolescents, and requires immediate surgical consultation 3, 1, 2
• Do not restrict STI coverage to young patients only: Molecular diagnostics show STIs occur across age groups, with C. trachomatis found in 14% of all cases regardless of age 5
• Do not assume viral etiology: Enteroviruses were found in only 1% of cases using comprehensive PCR testing, making viral epididymitis exceedingly rare 5
• Do not undertreate duration: The full 10-day course is essential to prevent complications including infertility and chronic scrotal pain 3, 6, 4