What are the treatment recommendations for epididymitis based on patient age?

Epididymitis Treatment by Age

For men under 35 years old, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men 35 years and older, use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Age-Based Treatment Algorithm

Men Under 35 Years Old (Sexually Active)

Primary pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae 1, 2, 3

Recommended regimen:

• Ceftriaxone 250 mg IM as a single dose
• PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 4

This combination targets both gonococcal and chlamydial infections, which are the predominant sexually transmitted pathogens in this age group 1. The treatment achieves microbiologic cure, improves symptoms, prevents transmission, and decreases complications such as infertility and chronic pain 1.

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 to cover enteric organisms like E. coli 2

Men 35 Years and Older

Primary pathogens: Gram-negative enteric organisms (especially E. coli) associated with urinary tract abnormalities or bladder outlet obstruction 1, 2

Recommended regimen (choose one):

• Ofloxacin 300 mg orally twice daily for 10 days 1
• OR Levofloxacin 500 mg orally once daily for 10 days 1

Fluoroquinolones provide adequate coverage for enteric bacteria and have excellent penetration into genital tissues 5, 6. This regimen also applies to patients allergic to cephalosporins and/or tetracyclines regardless of age 1.

Adjunctive Therapy (All Ages)

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1

Critical Follow-Up Points

Reassess within 3 days: Failure to improve requires reevaluation of both diagnosis and therapy 1. Consider alternative diagnoses including testicular torsion (surgical emergency), tumor, abscess, testicular cancer, tuberculosis, or fungal epididymitis 1, 2.

Partner Management (Sexually Transmitted Cases)

For confirmed or suspected N. gonorrhoeae or C. trachomatis infections:

• Refer all sexual partners from the preceding 60 days for evaluation and treatment 1
• Instruct patients to avoid sexual intercourse until both patient and partners complete therapy and are asymptomatic 1

Common Pitfalls to Avoid

Do not use ciprofloxacin as first-line for young men under 35: Quinolones are inadequate for chlamydial infections, which are the predominant pathogen in sexually active young men 7. The combination of ceftriaxone plus doxycycline is essential 2, 3.

Do not overlook urinary tract abnormalities in older men: Men over 35 with epididymitis often have underlying bladder outlet obstruction or anatomical abnormalities requiring further urological evaluation 1, 5, 2.

HIV-infected patients: Use the same treatment regimens, but maintain higher suspicion for fungal and mycobacterial causes, especially in immunosuppressed patients 1.