Treatment of Acute Epididymo-orchitis
For sexually active men under 35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years or those with enteric risk factors, 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 Under 35 Years (Sexually Active)
Primary pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae 3, 4
Recommended regimen:
- Ceftriaxone 250 mg IM single dose (or 1 g IM/IV per updated EAU guidelines) 3, 1
- PLUS Doxycycline 100 mg orally twice daily for 10 days 3, 1, 5
This dual therapy addresses both gonococcal and chlamydial infections, which are the predominant causes in this age group 2, 4. The 10-day doxycycline course is critical as C. trachomatis epididymitis accounts for two-thirds of cases in young men and is associated with oligospermia if untreated 6.
Men Who Practice Insertive Anal Intercourse
Additional pathogen: Sexually transmitted Escherichia coli and other enteric organisms 2, 4
Recommended regimen:
The fluoroquinolone provides coverage for enteric organisms while ceftriaxone addresses STI pathogens 4.
Men Over 35 Years or With Enteric Risk Factors
Primary pathogens: Enterobacterales (especially E. coli) from urinary reflux 3, 1
Risk factors include: Benign prostatic hyperplasia, urethral stricture, recent urinary instrumentation, or anatomical abnormalities 1, 7
Recommended regimen (choose one):
- Levofloxacin 500 mg orally once daily for 10 days 1, 2
- OR Ofloxacin 300 mg orally twice daily for 10 days 3, 1, 4
Fluoroquinolones achieve excellent penetration into epididymal and testicular tissue 7. However, rising ciprofloxacin resistance in E. coli necessitates careful antimicrobial selection 7.
Alternative Regimens for Allergies
For cephalosporin and/or tetracycline allergies:
- Ofloxacin 300 mg orally twice daily for 10 days 3, 2
- OR Levofloxacin 500 mg orally once daily for 10 days 2
For gonococcal infections with cephalosporin allergy, the EAU guidelines suggest gentamicin 240 mg IM single dose plus azithromycin 2 g orally single dose 3.
Essential Adjunctive Measures
All patients require:
- Bed rest until fever and inflammation subside 3, 1, 2
- Scrotal elevation to reduce pain and swelling 3, 1, 2
- Analgesics for pain control 3, 1, 2
These supportive measures are critical while antibiotics address the underlying infection 1.
Critical Follow-Up Parameters
Reassess at 3 days: Failure to improve within 72 hours mandates reevaluation of both diagnosis and therapy 3, 1, 2
Consider hospitalization if:
- Severe pain suggesting alternative diagnoses (especially testicular torsion) 1, 2
- Fever present 2
- Concerns about medication compliance 2
Persistent symptoms after completing antibiotics require comprehensive evaluation for:
- Testicular cancer 3, 1, 2
- Abscess formation 3, 1
- Tuberculous or fungal epididymitis 3, 2
- Testicular infarction 3, 1
- Tumor 3, 1
Management of Sexual Partners
For STI-related epididymitis:
- Refer all sexual partners from the preceding 60 days for evaluation and treatment 3, 1, 2
- Patients must abstain from sexual intercourse until both partners complete therapy and are asymptomatic 3, 1, 2
Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease, even when asymptomatic 6.
Diagnostic Workup Before Treatment
Essential tests:
- Gram stain of urethral exudate for urethritis (≥5 PMNs per oil immersion field) and presumptive gonococcal diagnosis 3, 2
- Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 3, 2
- First-void urine examination for leukocytes if urethral Gram stain negative 3, 2
- Syphilis serology and HIV testing 3, 2
In up to 90% of cases, pathogens migrate from the urethra or bladder and can be identified through appropriate diagnostics 3.
Special Populations
HIV-infected patients: Receive the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 3, 1, 2
Caveat: Fungi and mycobacteria are more likely causes in immunosuppressed patients and should be considered if standard therapy fails 3, 2.
Patients with indwelling catheters: Require empiric coverage with both a fluoroquinolone and third-generation cephalosporin until susceptibility testing is available due to high risk of multidrug-resistant organisms 8.
Critical Pitfall: Testicular Torsion
Testicular torsion is a surgical emergency that must be excluded 1, 2. Torsion is more frequent in adolescents and patients without evidence of inflammation or infection 3. Emergency surgical consultation is indicated when:
- Sudden onset of severe pain 3
- Test results do not confirm urethritis or urinary tract infection 3
- Testis is in abnormal position 2
Surgical Intervention Criteria
Surgery is indicated when:
- No clinical improvement within 48-72 hours of conservative treatment 9
- Presence of large abscesses or extensive malacia 9
- Loss of differentiation between epididymis and testis with hydrocele 9
However, 88% of epididymal abscesses can be successfully treated without surgery 8.
Long-Term Considerations
Fertility impact: Approximately 40% of patients develop post-inflammatory subfertility 8. Virulence factors like hemolysin A produced by uropathogenic E. coli negatively impact semen parameters 8.
Recurrence: Only 10% of men experience relapse 8. Recurrent cases warrant thorough evaluation for subvesical obstruction, and some patients may benefit from prophylactic vasectomy 8.