What is the recommended treatment for epididymoorchitis?

Treatment of Epididymoorchitis

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 organism 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 Active)

• Primary regimen: Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This targets the most common pathogens in this age group: Chlamydia trachomatis and Neisseria gonorrhoeae 1
• The combination is critical because gonorrhea resistance to fluoroquinolones is now widespread, making ceftriaxone essential for gonococcal coverage 3

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) 4
• This population requires coverage for sexually transmitted E. coli and other enteric organisms in addition to typical STI pathogens 1, 4

Men Over 35 Years or With Enteric Risk Factors

• 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 population, especially with bladder outlet obstruction, benign prostatic hyperplasia, or recent urinary instrumentation 2, 4
• Important caveat: Rising fluoroquinolone resistance in E. coli is becoming problematic, though these remain guideline-recommended first-line agents 5

Patients With Cephalosporin or Tetracycline Allergies

• Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days as alternative therapy 6, 1

Essential Adjunctive Measures

• Bed rest and scrotal elevation until fever and local inflammation resolve 1, 2
• Analgesics for pain control until symptoms subside 1, 2
• These supportive measures reduce pain and swelling while antibiotics address the infection 2

Critical Diagnostic Considerations Before Treatment

• Rule out testicular torsion first—this is a surgical emergency that presents with sudden severe pain and occurs more frequently in adolescents 6, 2
• Perform Gram stain of urethral exudate or intraurethral swab to diagnose urethritis (>5 PMNs per oil immersion field) and presumptively identify gonorrhea 1
• Obtain culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 1
• Examine first-void urine for leukocytes if urethral Gram stain is negative 1
• Perform syphilis serology and offer HIV counseling and testing 1

Follow-Up and Treatment Failure

• Reassess within 3 days if no clinical improvement occurs—this requires reevaluation of both diagnosis and therapy 1, 2
• Persistent swelling or tenderness after completing antibiotics demands comprehensive evaluation for alternative diagnoses including tumor, abscess, testicular infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis 1, 2
• Consider hospitalization for severe pain suggesting alternative diagnoses, fever, or concerns about medication compliance 1, 2
• In one study, 14.6% of patients with moderate disease (stage 2) and the majority of patients with severe disease (stage 3) required organ-sparing surgery when conservative treatment failed within 48-72 hours 7

Management of Sexual Partners

• For STI-related epididymoorchitis, refer sexual partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1, 2
• Patients must avoid sexual intercourse until both they and their partners complete therapy and become asymptomatic 1, 2

Special Populations

HIV-Positive Patients

• Use the same treatment regimen as HIV-negative patients for uncomplicated epididymoorchitis 1, 2
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients and should be considered if standard therapy fails 1, 2

Common Pitfalls to Avoid

• Do not miss testicular torsion—if sudden onset, severe pain, or examination findings are atypical, consult urology immediately as testicular viability may be compromised 6, 2
• Do not use fluoroquinolones alone in men under 35 or those at risk for gonorrhea—quinolone-resistant gonorrhea is now widespread 3
• Do not undertreate chlamydia—real-world data show only 18% of patients in UK primary care received doxycycline, and fewer than 3% were tested for chlamydia, representing significant guideline non-adherence 8
• Do not ignore persistent symptoms—failure to improve within 3 days mandates diagnostic reconsideration 1, 2