What is the treatment for epididymitis?

Treatment for 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. 1, 2

Etiology-Based Treatment Algorithm

Age and Sexual Activity Determine Pathogen and Treatment

Men under 35 years (sexually active):

• Most commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae 2, 3
• Recommended regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 4, 1, 2, 5
• This combination provides coverage for both gonococcal and chlamydial infections 1

Men who practice insertive anal intercourse:

• Enteric organisms (particularly E. coli) are likely pathogens in addition to STIs 2, 3
• Use 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 1, 2
• The fluoroquinolone provides enteric coverage that doxycycline lacks 6

Men over 35 years:

• Usually caused by enteric bacteria (E. coli predominates) secondary to bladder outlet obstruction 3, 6, 7
• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days alone is sufficient 1, 2
• Fluoroquinolones show >85% susceptibility for cultured bacteria in antibiotic-naive patients 6

Alternative Regimens for Allergies

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days 4, 2
• Levofloxacin 500 mg orally once daily for 10 days 1, 2

Critical Diagnostic Steps Before Treatment

Perform these tests to guide therapy:

• Gram stain of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1, 2
• Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis from intraurethral swab or first-void urine 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 1, 2
• Syphilis serology and HIV testing 4, 1, 2

Adjunctive Measures

All patients require supportive care:

• Bed rest until fever and inflammation subside 4, 1, 2
• Scrotal elevation 4, 1, 2
• Analgesics for pain control 4, 1, 2

Follow-Up and Red Flags

Reassess within 3 days if no improvement occurs 1, 2

Persistent symptoms after completing antibiotics warrant comprehensive evaluation for:

• Testicular tumor 1, 2
• Abscess formation 1, 2
• Testicular infarction 1, 2
• Testicular cancer 1, 2
• Tuberculous or fungal epididymitis 4, 1, 2

Management of Sexual Partners

For STI-related epididymitis:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 2
• Patient must avoid sexual intercourse until both patient and partner(s) complete therapy and are asymptomatic 1, 2
• Contact tracing is essential to prevent reinfection and transmission 2

Special Populations

HIV-positive patients:

• Receive the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 1, 2
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 4, 1, 2

Hospitalization indications:

• Severe pain suggesting alternative diagnoses (especially testicular torsion) 2
• Fever present 2
• Concerns about medication compliance 2

Common Pitfalls to Avoid

Do not use ciprofloxacin as first-line for young men: Despite being commonly prescribed by 71% of urologists in practice surveys, ciprofloxacin is not optimal for chlamydial infections 8. The guidelines clearly specify doxycycline for this age group 1, 2.

Do not assume STIs only occur in men under 35: Recent molecular diagnostic studies show STIs (particularly C. trachomatis) are not restricted to younger age groups and were found in 14% of all cases across all ages 6.

Always rule out testicular torsion first: Especially in adolescents and when pain onset is sudden and severe, as this requires immediate surgical consultation 1.