What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For men under 35 years with epididymitis, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years or those with suspected enteric organisms, 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 <35 Years (Sexually Transmitted Etiology)

The primary pathogens in this age group are Chlamydia trachomatis and Neisseria gonorrhoeae, though STIs are not strictly limited to younger patients and have been documented across all age groups 3, 4.

Recommended regimen:

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 5, 1, 2
• This combination provides coverage for both gonorrhea and chlamydia 5
• The FDA-approved doxycycline dosing for acute epididymo-orchitis caused by C. trachomatis or N. gonorrhoeae is 100 mg orally twice daily for at least 10 days 6

Special consideration for men who practice insertive anal intercourse:

• Use ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 4
• This provides additional coverage for enteric organisms like E. coli that can cause sexually transmitted epididymitis in this population 5

Men >35 Years (Enteric Organism Etiology)

Epididymitis in this age group is typically caused by Gram-negative enteric organisms, particularly Escherichia coli (56% of cases), often secondary to bladder outlet obstruction or recent urinary tract instrumentation 5, 3, 4.

Recommended regimen:

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2, 4
• Fluoroquinolones demonstrate >85% susceptibility against cultured bacteria in antibiotic-naive patients 3
• Ofloxacin is contraindicated in persons ≤17 years of age 5

Adjunctive Measures

All patients should receive:

• Bed rest and scrotal elevation until fever and local inflammation subside 5, 1, 2
• Analgesics for pain management 1
• Adequate fluid intake with doxycycline to reduce esophageal irritation risk 6

Critical Diagnostic Considerations

Rule out testicular torsion first, especially in adolescents, as this is a surgical emergency requiring immediate intervention 5, 1, 2. Emergency testing is indicated when pain onset is sudden and severe 2.

Diagnostic workup should include:

• Gram-stained smear of urethral exudate showing ≥5 polymorphonuclear leukocytes per oil immersion field 5, 1, 2
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 1, 2
• Culture and Gram-stained smear of uncentrifuged urine for Gram-negative bacteria 5, 1
• Syphilis serology and HIV counseling/testing 1, 2

Follow-Up and Treatment Failure

Reassess within 3 days if no improvement occurs 5, 1, 2. Failure to improve requires reevaluation of both diagnosis and therapy, with consideration for hospitalization 5.

Persistent swelling and tenderness after completing antimicrobial therapy warrants evaluation for:

• Testicular cancer 5, 1
• Tuberculous or fungal epididymitis (especially in immunocompromised patients) 5, 1
• Testicular abscess or infarction 1, 2

Management of Sexual Partners

For STI-related epididymitis:

• Refer sex partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1, 2
• Patients must avoid sexual intercourse until both patient and partner(s) complete therapy and are symptom-free 5, 1, 2

Special Populations

HIV-infected patients with uncomplicated epididymitis should receive the same treatment regimen as HIV-negative patients 5, 1, 2. However, fungi and mycobacteria should be considered more strongly in immunocompromised patients 1, 2.

Common Pitfalls

Avoid ciprofloxacin as first-line therapy in young men, as it is not optimal for urogenital chlamydial infection despite being commonly prescribed 7. The evidence shows that even in antimicrobially pretreated patients, bacterial etiology predominates (88% detection rate in naive patients), making appropriate empirical coverage essential 3.

Do not assume age-based etiology is absolute: STIs were found in 14% of cases across all age groups in contemporary studies, not just in patients under 35 years 3.

Hospitalization Criteria

Consider hospitalization for:

• Severe pain suggesting torsion, infarction, or abscess 1
• Febrile patients 1
• Patient noncompliance with antimicrobial regimen 1