What is the recommended treatment for epididymitis or orchitis?

Treatment of Epididymitis and Orchitis

Empiric antibiotic therapy should be initiated immediately based on patient age and likely pathogen, with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 10 days as first-line treatment for sexually active men under 35 years, and fluoroquinolones (levofloxacin 500 mg daily or ofloxacin 300 mg twice daily for 10 days) for men over 35 years or those with suspected enteric organisms. 1

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Pathogens)

Primary pathogens: Neisseria gonorrhoeae and Chlamydia trachomatis 2, 3

Recommended regimen:

• Ceftriaxone 250 mg IM as a single dose 1, 4
• PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 4

This combination achieves microbiologic cure, prevents transmission, reduces complications including infertility and chronic pain, and improves symptoms 1

Men Over 35 Years or With Enteric Organism Suspicion

Primary pathogens: Gram-negative enteric organisms, often associated with bladder outlet obstruction or recent urinary instrumentation 1, 5

Recommended regimen (choose one):

• Levofloxacin 500 mg orally once daily for 10 days 1
• OR Ofloxacin 300 mg orally twice daily for 10 days 1

Note: Rising fluoroquinolone resistance in E. coli is an emerging concern, though these remain guideline-recommended first-line agents 5

Men Who Practice Insertive Anal Intercourse

Likely pathogens: Both sexually transmitted organisms AND enteric bacteria 2

Recommended regimen:

• Ceftriaxone 250 mg IM single dose 2
• PLUS Levofloxacin 500 mg daily for 10 days OR Ofloxacin 300 mg twice daily for 10 days 2

Alternative Regimens for Allergies

For patients allergic to cephalosporins and/or tetracyclines, fluoroquinolones (levofloxacin or ofloxacin) are recommended 1

Essential Adjunctive Measures

All patients require:

• Bed rest until fever and inflammation subside 1
• Scrotal elevation 1
• Analgesics for pain control 1

These supportive measures are critical components of therapy, not optional 6

Diagnostic Workup Before Treatment

While empiric therapy should begin immediately, obtain the following 1, 6:

• Gram-stained urethral smear: ≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis 1, 6
• Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine 1, 6
• First-void urine examination for leukocytes if urethral Gram stain is negative 1, 6
• Syphilis serology and HIV testing 1, 6

Critical Follow-Up Parameters

Reassess within 3 days: Failure to improve requires immediate reevaluation of both diagnosis and treatment 1, 6

Persistent symptoms after completing antibiotics warrant comprehensive evaluation for:

• Testicular cancer 1, 6
• Abscess formation 1, 6
• Testicular infarction 1, 6
• Tuberculosis or fungal epididymitis 1, 6
• Tumor 1, 6

Management of Sexual Partners

For STI-related epididymitis:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 6
• Patients must abstain from sexual intercourse until both they and their partners complete therapy and are symptom-free 1, 6

Critical Differential Diagnosis

Testicular torsion must be excluded immediately, especially in adolescents, as it is a surgical emergency requiring urgent specialist consultation 1, 6

Red flags for torsion:

• Sudden onset of severe pain 6
• Absence of inflammatory signs or urinary symptoms 1
• Abnormal testicular position or absent cremasteric reflex 3

If diagnosis is uncertain, emergency surgical consultation is mandatory as testicular viability is time-dependent 1, 6

Special Populations

HIV-Positive Patients

• Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 1, 6
• Consider atypical pathogens: Fungi and mycobacteria are more common in immunosuppressed patients 1, 6

Hospitalization Indications

Consider inpatient management when 1:

• Severe pain suggests alternative diagnoses (torsion, abscess, infarction) 1
• Patient is febrile 1
• Concerns about treatment adherence exist 1

Common Pitfalls to Avoid

Do not delay treatment waiting for culture results—empiric therapy prevents complications including infertility 1, 2

Do not miss testicular torsion—this surgical emergency can mimic epididymitis but requires immediate intervention 6, 3

Do not forget partner treatment—untreated partners lead to reinfection and continued transmission 1, 6

Do not ignore treatment failure at 3 days—this mandates diagnostic reconsideration, not simply continuing the same antibiotics 1, 6