What is the treatment for epididymitis?

Treatment of Epididymitis

Treat epididymitis empirically based on patient age and sexual activity: for sexually active men under 35 years, use ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years or those with enteric organism risk, use a fluoroquinolone (ofloxacin 300 mg or levofloxacin 500 mg orally) twice daily for 10 days. 1

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

• Primary pathogens: Neisseria gonorrhoeae and Chlamydia trachomatis are the predominant causes in this age group 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 provides coverage for both gonococcal and chlamydial infections, which together account for the majority of sexually transmitted epididymitis 2

Men Who Practice Insertive Anal Intercourse

• Additional pathogen consideration: Enteric organisms (particularly E. coli) are likely in addition to STI pathogens 1, 2
• Recommended regimen: 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
• The fluoroquinolone component provides enteric organism coverage that doxycycline lacks 2

Men Over 35 Years

• Primary pathogens: Enteric bacteria (predominantly E. coli) transported by reflux of urine into ejaculatory ducts, typically secondary to bladder outlet obstruction 1, 2
• Recommended regimen: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
• Fluoroquinolone monotherapy is sufficient as STI pathogens are less common in this age group 2

Important caveat: Recent evidence shows that STIs, particularly C. trachomatis, are not strictly limited to men under 35 years and were found in 14% of cases across all age groups 5. Consider dual therapy if sexual activity or STI risk factors are present regardless of age.

Adjunctive Therapy

• Supportive measures: Bed rest, scrotal elevation, and analgesics should be continued until fever and local inflammation subside 1
• These measures reduce morbidity and improve patient comfort during the acute inflammatory phase 1

Follow-Up and Treatment Failure

• Reassessment timeline: Failure to improve within 3 days requires reevaluation of both diagnosis and therapy 1
• Persistent symptoms: Swelling and tenderness persisting after antimicrobial completion warrant comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis 1
• Untreated or inadequately treated epididymitis can lead to infertility and chronic scrotal pain, making appropriate initial therapy critical 2

Partner Management

• Partner notification: Sex partners should be evaluated and treated if contact occurred within 60 days preceding symptom onset in patients with confirmed or suspected N. gonorrhoeae or C. trachomatis infection 1
• Sexual abstinence: Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 1
• Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease and require treatment 3

Special Populations

HIV-Infected Patients

• Standard therapy applies: HIV-positive patients with uncomplicated epididymitis receive the same treatment regimens as HIV-negative patients 1
• Opportunistic pathogens: Fungi and mycobacteria cause epididymitis more frequently in immunosuppressed patients and should be considered if standard therapy fails 1

Hospitalization Criteria

• Consider admission when: Severe pain suggests alternative diagnoses (testicular torsion, infarction, abscess), patients are febrile, or concern exists about antimicrobial compliance 1
• Testicular torsion remains a surgical emergency that must be excluded, particularly in adolescents and when pain onset is sudden or severe 1

Diagnostic Considerations Before Treatment

• Urethral evaluation: Gram stain of urethral exudate (≥5 PMNs per oil immersion field indicates urethritis) and culture or nucleic acid amplification testing for N. gonorrhoeae and C. trachomatis 1
• Urine analysis: First-void urine examination for leukocytes with culture and Gram stain if urethral Gram stain is negative 1
• Additional testing: Syphilis serology and HIV counseling should be offered 1

Critical pitfall: Studies show that CDC guidelines for evaluation and treatment are followed in less than 35% of cases in clinical practice, with many patients receiving inappropriate empirical antibiotics 6. Adherence to age-based treatment algorithms significantly improves outcomes and reduces complications including infertility 2, 6.