What is the treatment for epididymis pain?

Treatment of Epididymis Pain

For sexually active men under 35 years, treat empirically with 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 ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Critical First Step: Rule Out Testicular Torsion

• Testicular torsion is a surgical emergency that must be excluded immediately, especially when pain onset is sudden, pain is severe, or initial testing doesn't support urethritis/urinary tract infection 1
• Consult a specialist immediately if diagnosis is questionable, as testicular viability may be compromised 1
• Torsion occurs more frequently in adolescents and men without evidence of inflammation or infection 1

Diagnostic Evaluation Before Treatment

Perform these tests to guide therapy:

• Gram stain of urethral exudate or intraurethral swab for urethritis (>5 PMNs per oil immersion field) and presumptive gonococcal diagnosis 1
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 1
• First-void urine examination for leukocytes if urethral Gram stain is negative, with culture and Gram stain 1
• Syphilis serology and HIV testing should be offered 1

Age-Based Treatment Algorithm

Men <35 Years (Sexually Active)

Primary pathogens: C. trachomatis and N. gonorrhoeae 1, 2

Standard regimen:

• Ceftriaxone 250 mg IM single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 3

Special consideration for men who practice insertive anal intercourse:

• Enteric organisms (E. coli) are also likely 1
• 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

Men ≥35 Years

Primary pathogens: Gram-negative enteric organisms (especially E. coli) associated with bladder outlet obstruction, urinary tract instrumentation, or anatomical abnormalities 1, 2

Standard regimen:

• Ofloxacin 300 mg orally twice daily for 10 days 1
• OR Levofloxacin 500 mg orally once daily for 10 days 1

Important caveat: Recent data shows rising fluoroquinolone resistance in E. coli, which may necessitate alternative antimicrobials based on local resistance patterns 4

Patients with Cephalosporin/Tetracycline Allergies

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

Adjunctive Supportive Measures

These measures should be continued until fever and local inflammation subside:

• Bed rest 1
• Scrotal elevation 1
• Analgesics 1

Hospitalization Criteria

Consider inpatient management when:

• Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess) 1
• Fever is present 1
• Patient may be noncompliant with antimicrobial regimen 1

Follow-Up and Treatment Failure

• Reassess within 3 days if no improvement in symptoms 1
• Reevaluate both diagnosis and therapy if treatment fails 1
• If swelling and tenderness persist after completing antimicrobials, comprehensively evaluate for: tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1

Sex Partner Management

For epididymitis caused by or suspected to be caused by N. gonorrhoeae or C. trachomatis:

• Refer sex partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
• Instruct patients to avoid sexual intercourse until both patient and partners complete therapy and are asymptomatic 1

Special Populations

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 1
• Be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Key Clinical Pearls

• STIs are not limited to men <35 years: Recent data shows C. trachomatis can occur across all age groups, with 14% of cases being STI-related regardless of age 5
• Empiric therapy is indicated before culture results to prevent complications including infertility and chronic pain 1, 2
• Only 50% of men with epididymitis are tested for gonorrhea and chlamydia in emergency settings, representing a significant gap in care 6
• E. coli remains the most common bacterial pathogen overall, found in 56% of cases in recent studies 5
• Viral epididymitis is rare, found in only 1% of comprehensively tested patients 5