Management of Epididymoorchitis
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 to cover gonococcal and chlamydial infections. 1
Initial Assessment and Diagnosis
Rule out testicular torsion immediately - this is a surgical emergency requiring intervention within 4-6 hours to preserve testicular viability. 2 Torsion is more common in adolescents and presents with sudden onset severe pain without evidence of inflammation or infection. 2 If diagnosis is uncertain, consult urology emergently. 2
Diagnostic Workup
Obtain the following before starting empiric antibiotics:
- Urethral Gram stain for urethritis (≥5 PMNs per oil immersion field) and presumptive gonococcal diagnosis 2
- Nucleic acid amplification test (NAAT) or culture from urethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 2
- First-void urine examination for leukocytes if urethral Gram stain is negative, plus culture and Gram stain of uncentrifuged urine 2
- Syphilis serology and offer HIV testing 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Active)
Standard regimen:
This covers N. gonorrhoeae and C. trachomatis, the most common pathogens in this age group. 4
For men who practice insertive anal intercourse:
- 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
This broader coverage addresses enteric organisms in addition to STIs. 4
Men Over 35 Years
Enteric organisms (particularly E. coli) are the primary pathogens, often associated with bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture. 2, 5
Treatment:
- Levofloxacin 500 mg orally once daily for 10 days OR
- Ofloxacin 300 mg orally twice daily for 10 days 1, 4
Note: Rising fluoroquinolone resistance in E. coli is a growing concern, so consider local antibiogram data. 5
Patients with Cephalosporin or Tetracycline Allergy
- Ofloxacin 300 mg orally twice daily for 10 days 1
Supportive Care
All patients require:
- Bed rest until fever and inflammation subside 2, 1
- Scrotal elevation 2, 1
- Analgesics for pain control 2, 1
Hospitalization Criteria
Consider admission for:
- Severe pain suggesting complications (torsion, testicular infarction, abscess) 2
- Febrile patients 2
- Concern for medication non-compliance 2
- Lack of clinical improvement within 48-72 hours of outpatient treatment 6
Follow-Up and Treatment Failure
Reassess within 3 days if symptoms do not improve - this requires reevaluation of both diagnosis and treatment. 2, 1
Persistent swelling or tenderness after completing antibiotics warrants comprehensive evaluation for:
- Testicular tumor or cancer 2, 1
- Abscess formation 2, 1
- Testicular infarction 2, 1
- Tuberculous or fungal epididymitis 2, 1
Patients without clinical improvement within 48-72 hours may require organ-sparing surgery, particularly if hydrocele and abscesses are present. 6
Sexual Partner Management
For STI-related cases:
- Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 2, 1
- Patient must abstain from sexual intercourse until both partners complete therapy and are asymptomatic 2, 1
- Failure to treat partners leads to reinfection 1
Special Populations
HIV-Infected Patients
- Use the same treatment regimen as HIV-negative patients for uncomplicated cases 2, 1
- However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 2, 1
Critical Pitfalls to Avoid
- Missing testicular torsion - always consider this diagnosis first, especially in adolescents with acute scrotal pain 1
- Inadequate partner treatment - this perpetuates infection cycles 1
- Premature discontinuation of antibiotics - complete the full 10-day course even if symptoms improve 3
- Ignoring treatment failure - persistent symptoms after 3 days mandate diagnostic reassessment 1
- Overlooking bladder outlet obstruction in older men - this predisposes to recurrent infections 5