What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For sexually active men under 35 years with epididymitis, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia. 1

Etiology-Based Treatment Selection

The treatment approach depends critically on patient age and sexual practices, as these determine the likely causative organisms:

Men Under 35 Years (Sexually Active)

• Primary regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 2, 1
• This combination targets Neisseria gonorrhoeae and Chlamydia trachomatis, which account for the majority of cases in this age group 3, 4
• C. trachomatis alone causes approximately two-thirds of previously "idiopathic" epididymitis cases in young men and is frequently associated with oligospermia 4, 5

Men Who Practice Insertive Anal Intercourse

• Ceftriaxone 250 mg IM single dose PLUS either levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
• The fluoroquinolone component provides coverage for enteric organisms (E. coli) in addition to STIs 2, 3

Men Over 35 Years or With Urinary Tract Abnormalities

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2, 1
• Escherichia coli and other enteric bacteria predominate in this population, typically secondary to bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture 3, 4, 5
• Fluoroquinolone monotherapy provides adequate coverage, though rising ciprofloxacin resistance is a growing concern 6

Patients With Cephalosporin or Tetracycline Allergies

• Ofloxacin 300 mg orally twice daily for 10 days 2, 1

Critical Diagnostic Considerations

Before initiating treatment, obtain:

• Urethral Gram stain showing ≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis 2
• Urethral culture or nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis 2, 1
• First-void urine culture and Gram stain for enteric bacteria 2, 1

Testicular torsion must be excluded in all cases, particularly in adolescents with sudden onset of severe pain 1. This is a surgical emergency requiring immediate intervention, not antibiotics.

Adjunctive Supportive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 2, 1
• These measures are recommended as adjuncts to antimicrobial therapy 2

Follow-Up and Treatment Failure

• Reevaluate within 3 days if symptoms do not improve 2, 1
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 2, 1

Management of Sexual Partners

• All sexual partners with contact within 60 days preceding symptom onset must be evaluated and treated empirically 2, 1
• Partners should receive treatment effective against both N. gonorrhoeae and C. trachomatis regardless of the patient's test results, as diagnostic tests have limited sensitivity in asymptomatic men 2
• Patients must abstain from sexual intercourse until both they and their partners complete treatment and are asymptomatic 2, 1
• Among female partners of men with C. trachomatis epididymitis, approximately two-thirds have antibody evidence of infection, with some having active cervical infection or pelvic inflammatory disease 4, 5

Special Populations

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 2, 1
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients and should be considered if standard therapy fails 2, 1

Pregnant Women's Partners

• Standard treatment regimens apply, but ensure partner treatment to prevent reinfection 2

Common Pitfalls to Avoid

• Do not assume STIs are limited to men under 35 years—recent data show STIs occur across all age groups 7
• Do not fail to treat sexual partners—this leads to reinfection and continued transmission 1
• Do not delay evaluation for testicular torsion when clinical presentation is atypical, as misdiagnosis can result in testicular loss 1
• Do not use empiric therapy without attempting microbiologic diagnosis—comprehensive diagnostics identify pathogens in 88% of antibiotic-naive patients 7
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making prompt recognition and appropriate therapy essential 3