What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

• Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2

  • This targets Chlamydia trachomatis and Neisseria gonorrhoeae, the predominant pathogens in this age group 1, 2, 4
  • C. trachomatis accounts for two-thirds of previously "idiopathic" epididymitis cases in young men 5, 6

• For men who practice insertive anal intercourse: Ceftriaxone 250 mg IM single dose PLUS either levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2

  • This broader coverage addresses enteric organisms (particularly E. coli) in addition to STIs 3, 1

Men Over 35 Years (Enteric Organism Etiology)

• Recommended regimen: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 3, 1, 2
  • Enteric Gram-negative bacteria, predominantly E. coli, cause epididymitis in this age group, typically associated with bladder outlet obstruction 3, 4
  • Critical caveat: Rising fluoroquinolone resistance in E. coli isolates may necessitate alternative antimicrobials, though specific alternatives are not well-established 7

Alternative Regimens for Drug Allergies

• For cephalosporin and/or tetracycline allergies: Ofloxacin 300 mg orally twice daily for 10 days 3, 1, 2
• Note: Ofloxacin is contraindicated in persons ≤17 years of age 3

Essential Supportive Measures

• Adjunctive therapy: Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 3, 1, 2
• These measures are recommended alongside antimicrobial therapy for all patients 1, 2

Diagnostic Evaluation Before Treatment

• Urethral Gram stain: Examine for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 3, 2
• Culture or nucleic acid amplification testing: Obtain intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 3, 2
• First-void urine examination: Check for leukocytes if urethral Gram stain is negative; culture uncentrifuged urine for Gram-negative bacteria 3
• Additional testing: Syphilis serology and HIV counseling/testing 3, 2

Critical Follow-Up Requirements

• Re-evaluate within 3 days if symptoms do not improve—this requires reassessment of both diagnosis and therapy 3, 1, 2
• Persistent swelling or tenderness after completing antimicrobials warrants comprehensive evaluation for testicular cancer, tuberculosis, fungal epididymitis, tumor, abscess, or infarction 3, 1, 2

Management of Sexual Partners

• Refer sexual partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset for STI-related epididymitis 1, 2
• Abstain from sexual intercourse until both patient and partner(s) complete therapy and are asymptomatic 3, 1, 2
• Female partners of men with C. trachomatis epididymitis frequently have infection or pelvic inflammatory disease and require treatment 5, 6

Common Pitfalls to Avoid

Testicular Torsion Misdiagnosis

• Always consider testicular torsion as a surgical emergency, especially in adolescents with acute scrotal pain 3, 1
• Torsion is more likely when pain onset is sudden, pain is severe, or initial testing does not confirm urethritis or urinary tract infection 3
• Emergency surgical consultation may be indicated when diagnosis is uncertain 3

Age-Based Treatment Errors

• Do not assume STIs are limited to men under 35 years—STIs were found in 14% of all epididymitis cases across age groups in recent studies 8
• Conversely, enteric organisms can cause epididymitis in younger men who practice insertive anal intercourse 3, 1

Inadequate Partner Treatment

• Failure to treat sexual partners leads to reinfection 1
• Partners should be evaluated even if asymptomatic, as C. trachomatis urethritis is often asymptomatic in the index patient 3

Special Populations

HIV-Infected Patients

• Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 3, 1, 2
• Fungi and mycobacteria are more likely causes in severely immunosuppressed patients 1, 2

Hospitalization Considerations

• Consider hospitalization when: severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess), patient is febrile, or concerns exist about medication compliance 3, 2

Oligospermia Risk

• C. trachomatis epididymitis is often associated with oligospermia, emphasizing the importance of prompt treatment to prevent infertility 5, 6