Treatment of Epididymo-Orchitis
For sexually active men under 35 years, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia. 1
Age-Based Treatment Algorithm
Men < 35 Years (Sexually Transmitted Pathogens)
The most common causative organisms in this age group are Chlamydia trachomatis and Neisseria gonorrhoeae, which require dual therapy 1:
This combination achieves microbiologic cure, prevents transmission, reduces complications (infertility, chronic pain), and improves symptoms 1.
Men Who Practice Insertive Anal Intercourse
These patients are at risk for enteric organisms (E. coli) in addition to sexually transmitted pathogens 1:
- Ceftriaxone 250 mg IM once 3
- PLUS Levofloxacin 500 mg orally once daily for 10 days 1
- OR Ofloxacin 300 mg orally twice daily for 10 days 1
Men ≥ 35 Years (Enteric Organisms)
Epididymo-orchitis in this age group is typically caused by gram-negative enteric organisms secondary to bladder outlet obstruction, benign prostatic hyperplasia, or urethral stricture 1, 4:
- Levofloxacin 500 mg orally once daily for 10 days 1
- OR Ofloxacin 300 mg orally twice daily for 10 days 1
Important caveat: Rising fluoroquinolone resistance in E. coli isolates is becoming problematic, and alternative antimicrobials may be needed if local resistance patterns are high 4.
Patients with Cephalosporin or Tetracycline Allergies
For patients who cannot tolerate first-line therapy 1:
- Ofloxacin 300 mg orally twice daily for 10 days 1
- OR Levofloxacin 500 mg orally once daily for 10 days 1
Adjunctive Therapy
All patients should receive supportive care until fever and local inflammation resolve 1:
Critical Follow-Up and Red Flags
Reassess within 3 days if no clinical improvement occurs 1. Failure to improve requires reevaluation of both diagnosis and therapy 1.
Differential Diagnosis for Treatment Failure
If swelling and tenderness persist after completing antimicrobial therapy, consider 1:
- Testicular torsion (surgical emergency—consult immediately if sudden onset, severe pain) 1
- Testicular tumor or cancer 1
- Abscess formation 1
- Testicular infarction 1
- Tuberculous or fungal epididymitis 1
Common pitfall: Testicular torsion occurs more frequently in adolescents and patients without evidence of inflammation or infection—if diagnosis is questionable, consult a specialist immediately as testicular viability may be compromised 1.
Partner Management and Sexual Activity
For sexually transmitted epididymo-orchitis, all sexual partners within 60 days preceding symptom onset must be evaluated and treated 1. Patients should avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 1.
Special Populations
HIV-Infected Patients
HIV-positive patients with uncomplicated epididymo-orchitis receive the same treatment regimen as HIV-negative patients 1. However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 1.
Patients with Indwelling Catheters
These patients are at high risk for multidrug-resistant organisms and should receive empiric treatment with both a fluoroquinolone and third-generation cephalosporin until antimicrobial susceptibility results are available 5.
Surgical Intervention
Surgery is indicated when conservative treatment fails within 48-72 hours 6. Approximately 88% of epididymal abscesses can be successfully treated without surgery, but organ-sparing surgery should be considered for patients with 6: