What is the treatment for epididymitis?

Treatment of Epididymitis

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

• Primary regimen: Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2, 4
• This dual therapy targets Neisseria gonorrhoeae and Chlamydia trachomatis, the most common pathogens in this age group 3, 2, 5
• Alternative regimen: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 3, 1
• Critical caveat: Ofloxacin is contraindicated in patients ≤17 years of age 3

Men Who Practice Insertive Anal Intercourse

• Use ceftriaxone 250 mg IM once PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 5
• This regimen covers enteric organisms (E. coli) in addition to sexually transmitted pathogens 3, 5

Men Over 35 Years

• Monotherapy with fluoroquinolone: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 5
• Epididymitis in this age group is typically caused by enteric bacteria (predominantly E. coli) secondary to bladder outlet obstruction 3, 5
• Fluoroquinolones alone provide adequate coverage for gram-negative enteric organisms 5, 6

Essential Adjunctive Therapy

• All patients require: Bed rest, scrotal elevation, and analgesics until fever and local inflammation resolve 3, 1, 2
• Administer adequate fluids with doxycycline to reduce risk of esophageal irritation and ulceration 4
• Doxycycline may be given with food or milk if gastric irritation occurs, as absorption is not significantly affected 4

Critical Diagnostic Considerations

Testicular torsion must be ruled out immediately in all cases, especially in adolescents, as this is a surgical emergency. 3, 1, 2

• Emergency testing for torsion is indicated when pain onset is sudden and severe, or when initial test results do not confirm urethritis or urinary tract infection 3, 1
• Testicular viability may be compromised without immediate specialist consultation 1

Recommended Diagnostic Workup

• Gram-stained smear of urethral exudate or intraurethral swab (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 3, 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 3, 1
• First-void urine examination for leukocytes if urethral Gram stain is negative 1
• Culture and Gram stain of uncentrifuged urine for gram-negative bacteria 3
• Syphilis serology and HIV counseling/testing 1

Follow-Up and Red Flags

• Reassess within 3 days if no clinical improvement occurs 3, 1, 2
• Failure to improve requires reevaluation of both diagnosis and therapy, with consideration of hospitalization 3, 1, 2
• Persistent swelling and tenderness after completing antimicrobial therapy warrants evaluation for testicular cancer, tuberculous epididymitis, fungal epididymitis, tumor, abscess, or infarction 3, 1

Management of Sexual Partners

• All sexual partners within 60 days preceding symptom onset must be evaluated and treated 1, 2
• Partners should be referred if contact occurred within 30 days of symptom onset for confirmed or suspected STI-related epididymitis 3, 1
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 3, 1, 2

Special Populations

HIV-Positive Patients

• HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients 3, 1, 2
• Fungi and mycobacteria are more likely causative organisms in immunosuppressed patients and should be considered if standard therapy fails 3, 1, 2

Important Clinical Pearls

• Recent evidence using advanced molecular diagnostics shows that bacterial pathogens are identified in 88% of antibiotic-naive patients, with E. coli accounting for 56% of cases 6
• STIs are not restricted to men under 35 years and were found in 14% of cases across all age groups in contemporary studies 6
• C. trachomatis epididymitis accounts for two-thirds of previously "idiopathic" cases and is often associated with oligozoospermia 7
• Untreated acute epididymitis can lead to infertility and chronic scrotal pain, making prompt recognition and therapy vital 5