Epididymitis Workup and Treatment
For sexually active men under 35 years, immediately initiate empiric therapy with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia, while simultaneously performing diagnostic testing including urethral Gram stain, NAAT for N. gonorrhoeae and C. trachomatis, and first-void urinalysis. 1, 2, 3
Initial Clinical Assessment
Rule out testicular torsion first - this is a surgical emergency that presents with sudden, severe pain and requires immediate specialist consultation, particularly in adolescents and when inflammation/infection markers are absent. 1, 2
Key Physical Examination Findings
- Unilateral testicular pain and tenderness 1, 2
- Palpable swelling of the epididymis 1, 2
- Hydrocele may be present 1, 2
- Testis should be in anatomically normal position (unlike torsion) 4
- Gradual onset of posterior scrotal pain (versus sudden in torsion) 4
Diagnostic Workup
Essential Laboratory Tests
Perform the following tests before culture results return, as empiric therapy must be started immediately: 1
Gram-stained smear of urethral exudate or intraurethral swab: Look for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis and presumptively identify gonococcal infection 1
Nucleic acid amplification test (NAAT): Either on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis (preferred over culture due to higher sensitivity) 1
First-void urine examination: If urethral Gram stain is negative, examine uncentrifuged urine for leukocytes; obtain culture and Gram stain of this specimen 1
Syphilis serology and HIV testing: Offer counseling and testing to all patients 1
Age-Based Etiology and Treatment Algorithm
Men Under 35 Years (Sexually Active)
Most common pathogens: C. trachomatis and N. gonorrhoeae 1, 3, 4, 5
Recommended regimen:
- Ceftriaxone 250 mg IM as single dose 1, 2, 3
- PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2, 3, 6
Men Who Practice Insertive Anal Intercourse
Additional pathogen consideration: Enteric organisms (E. coli) 1, 4
Recommended regimen:
- Ceftriaxone 250 mg IM as single dose 2, 3
- PLUS Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 1, 2, 3, 4
Men Over 35 Years
Most common pathogen: Enteric bacteria (E. coli) secondary to bladder outlet obstruction with urinary reflux into ejaculatory ducts 1, 4, 5, 7
Recommended regimen:
- Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 1, 2, 3, 4
Note: Recent data shows fluoroquinolones maintain >85% susceptibility against cultured bacteria in antibiotic-naive patients 7
Patients Allergic to Cephalosporins/Tetracyclines
Alternative regimen:
- Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 1, 2
Adjunctive Supportive Care
All patients require:
- Bed rest until fever and local inflammation subside 1, 2, 3
- Scrotal elevation until fever and local inflammation subside 1, 2, 3
- Analgesics until fever and local inflammation subside 1, 2, 3
Critical Follow-Up Parameters
Reassess within 3 days: If no clinical improvement occurs, reevaluate both diagnosis and therapy 1, 2, 3
Persistent symptoms after completing antibiotics warrant comprehensive evaluation for:
- Tumor 1, 2
- Abscess 1, 2
- Testicular infarction 1, 2
- Testicular cancer 1, 2
- Tuberculous epididymitis 1, 2
- Fungal epididymitis 1, 2
Sexual Partner Management
For STI-related epididymitis:
- Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 2, 3
- Patient must avoid sexual intercourse until both patient and partner(s) complete therapy and are asymptomatic 1, 2, 3
Special Populations
HIV-Positive Patients
- Treat with same regimen as HIV-negative patients for uncomplicated epididymitis 1, 2, 3
- However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients and should be considered if standard therapy fails 1, 2, 3
Prepubertal Children (Under 14 Years)
- Etiology is largely unknown; reflux of urine into ejaculatory ducts is most common cause 4
- Urine cultures are typically sterile (99% negative in one series) 8
- Antibiotic treatment should only be given if urine tests are positive 8
Hospitalization Criteria
Consider admission when: 1
- Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess) 1
- Patient is febrile 1
- Concern for noncompliance with oral antimicrobial regimen 1
Common Pitfalls
Do not assume STIs are limited to men under 35: Recent data shows STIs (particularly C. trachomatis) occur across all age groups, not just younger patients 7
Do not delay empiric therapy: Treatment must begin before culture results are available to prevent complications including infertility and chronic scrotal pain 1, 4
Do not miss testicular torsion: Emergency surgical consultation is mandatory when pain onset is sudden and severe, or when initial testing does not support urethritis/UTI 1, 2