What is the recommended 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; for men over 35 years or those with enteric organism risk, use levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

The primary pathogens in this age group are Chlamydia trachomatis and Neisseria gonorrhoeae, which account for the majority of cases in sexually active men. 2, 3

Standard regimen:

• Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 2, 1, 4
• This combination provides coverage for both gonococcal and chlamydial infections, which are often co-present 5, 6

Special consideration for men who practice insertive anal intercourse:

• 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
• This regimen covers enteric organisms (E. coli) in addition to sexually transmitted pathogens 2, 3

Men Over 35 Years (Enteric Organism Etiology)

Epididymitis in this population is typically caused by Gram-negative enteric organisms, particularly E. coli, often associated with bladder outlet obstruction from benign prostatic hyperplasia or prior urinary tract instrumentation. 2, 3

Recommended regimen:

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
• Fluoroquinolone monotherapy is sufficient as sexually transmitted pathogens are less common in this age group 2, 3

Important caveat: Rising fluoroquinolone resistance in E. coli isolates is becoming problematic, particularly in Europe and the USA, necessitating consideration of alternative antimicrobials with adequate genital tissue penetration if resistance is suspected. 7

Alternative Regimen for Allergies

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days 2

Essential Adjunctive Measures

Beyond antimicrobial therapy, supportive care is critical:

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2, 1
• These measures reduce pain and promote resolution of inflammation 2

Diagnostic Workup Before Treatment

Empiric therapy should be initiated immediately, but obtain these tests to guide management: 2

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

Critical Follow-Up and Red Flags

Reevaluate within 3 days if no clinical improvement occurs 2, 1

• Failure to improve requires reassessment of both diagnosis and antimicrobial choice 2
• Persistent swelling and tenderness after completing therapy warrants comprehensive evaluation for tumor, abscess, testicular infarction, testicular cancer, tuberculous or fungal epididymitis 2, 1

Rule out testicular torsion immediately in all cases, especially when:

• Pain onset is sudden and severe 2, 1
• Patient is an adolescent (torsion is more common in this age group) 2, 1
• No evidence of inflammation or infection is present 2
• Testicular torsion is a surgical emergency requiring immediate specialist consultation to preserve testicular viability 2, 1

Management of Sexual Partners

For epididymitis caused by sexually transmitted pathogens:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 2, 1
• Patients must avoid sexual intercourse until both they and their partners complete treatment and are symptom-free 2, 1
• Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease and require treatment 5

Special Populations

HIV-infected patients:

• Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 2, 1
• Be aware that fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 2, 1

Hospitalization considerations:

• Admit patients with severe pain suggesting alternative diagnoses (torsion, abscess, testicular infarction), fever, or anticipated noncompliance with oral antimicrobial therapy 2

Long-Term Complications

Untreated or inadequately treated epididymitis can lead to:

• Infertility (particularly with C. trachomatis infection, which is associated with oligospermia) 3, 5
• Chronic scrotal pain 2, 3

These potential complications underscore the importance of prompt recognition and appropriate antimicrobial therapy. 3