What is the treatment and management plan for acute epididymitis?

Treatment and Management Plan for Acute Epididymitis

Initial Diagnostic Evaluation

Before initiating empiric therapy, obtain specific diagnostic tests to guide treatment and identify sexually transmitted infections that require partner notification. 1

Perform the following diagnostic procedures:

• Gram-stained smear of urethral exudate or intraurethral swab to diagnose urethritis (>5 polymorphonuclear leukocytes per oil immersion field) and presumptively diagnose gonococcal infection 1
• Nucleic acid amplification test (NAAT) or culture of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
• First-void uncentrifuged urine examination for leukocytes if urethral Gram stain is negative, with culture and Gram stain of this specimen 1
• Syphilis serology and HIV testing with appropriate counseling 1

Critical pitfall: If testicular torsion cannot be excluded based on clinical presentation (sudden onset, severe pain) or initial test results, consult a specialist immediately as testicular viability may be compromised. 1

Age-Based Empiric Antibiotic Therapy

For Sexually Active Men Ages 14-35 Years

The standard regimen is ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2 This combination targets the most common pathogens in this age group: N. gonorrhoeae and C. trachomatis. 3, 4

Important caveat: Recent molecular diagnostic studies show that sexually transmitted infections are not strictly limited to patients under 35 years, so consider this regimen in older patients with risk factors for STIs. 5

For Men Who Practice Insertive Anal Intercourse

Use 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, 3 The fluoroquinolone component provides coverage for enteric organisms that are likely pathogens in this population. 3

For Men Over 35 Years or Enteric Organism Infection

Treat with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days as monotherapy. 1, 6 Enteric bacteria, predominantly E. coli, are the causative organisms in this population, typically secondary to bladder outlet obstruction causing urinary reflux into the ejaculatory ducts. 3, 5, 4

Recent studies confirm that fluoroquinolones maintain >85% susceptibility against cultured bacteria in antibiotic-naive patients. 5

For Patients with Cephalosporin or Tetracycline Allergies

Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Essential Adjunctive Therapy

All patients require bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1, 6 These supportive measures are mandatory components of treatment, not optional. 6

Administer adequate fluids with doxycycline to reduce the risk of esophageal irritation and ulceration. 2 If gastric irritation occurs, doxycycline may be given with food or milk without significantly affecting absorption. 2

Mandatory Follow-Up and Reevaluation

Reevaluate all patients within 72 hours (3 days) of initiating treatment. 1, 6 Failure to improve within this timeframe requires reassessment of both the diagnosis and therapy. 1, 6

If swelling and tenderness persist after completing the full antimicrobial course, perform comprehensive evaluation for alternative diagnoses including:

• Testicular tumor or cancer 1
• Abscess or testicular infarction 1
• Tuberculous or fungal epididymitis 1

Criteria for Hospitalization (Complicated Epididymitis)

Consider hospitalization for patients with:

• Severe pain suggesting alternative diagnoses such as testicular torsion, infarction, or abscess 6
• Immunocompromised status including advanced HIV infection, where fungal and mycobacterial causes are more likely 1, 6

For hospitalized patients with complicated epididymitis, fluoroquinolones (levofloxacin 500 mg once daily or ofloxacin 300 mg twice daily for 10 days) remain first-line treatment. 6

Partner Management and Sexual Activity Restrictions

Instruct patients with confirmed or suspected N. gonorrhoeae or C. trachomatis infection to refer all sex partners from the preceding 60 days for evaluation and treatment. 1 The older guideline recommended 30 days, but the more recent recommendation extends this to 60 days. 1

Patients must avoid all sexual intercourse until both they and their partners complete therapy and are asymptomatic. 1 This is critical because C. trachomatis epididymitis is often associated with oligospermia and can cause pelvic inflammatory disease in female partners. 4, 7

Studies demonstrate that among female sexual partners of men with C. trachomatis epididymitis, two-thirds have antibody evidence of infection, with many having active cervical infection or pelvic inflammatory disease. 4, 7

Special Populations

HIV-Infected Patients

Treat HIV-positive patients with uncomplicated epididymitis using the same regimens as HIV-negative patients. 1 However, maintain heightened suspicion for fungal and mycobacterial causes in immunosuppressed patients and consider more extensive microbiologic studies if standard therapy fails. 1, 6

Pediatric Patients Under 14 Years

In children younger than 14 years, reflux of urine into the ejaculatory ducts is the most common cause rather than sexually transmitted infections. 3 Treatment should focus on enteric organisms with fluoroquinolones, though note that ofloxacin is contraindicated in patients ≤17 years of age. 1

Treatment Duration

The minimum treatment duration for all epididymitis cases is 10 days. 1, 6, 2 Do not shorten the course even with early clinical improvement, as inadequate treatment can lead to chronic scrotal pain and infertility. 6, 3