Treatment of Epididymitis
For sexually active men under 35 years, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia. 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
The causative organisms in this age group are predominantly Neisseria gonorrhoeae and Chlamydia trachomatis, requiring dual antimicrobial coverage. 3, 2
Recommended regimen:
- Ceftriaxone 250 mg IM as a single dose 3, 1, 2
- PLUS Doxycycline 100 mg orally twice daily for 10 days 3, 1, 2, 4
Alternative regimen (if fluoroquinolones are appropriate):
- Ofloxacin 300 mg orally twice daily for 10 days 3, 1
- OR Levofloxacin 500 mg orally once daily for 10 days 1
- Note: Ofloxacin is contraindicated in persons ≤17 years of age 3
Men Who Practice Insertive Anal Intercourse
Enteric organisms (particularly E. coli) are more likely in this population, requiring broader coverage. 3, 5
Recommended regimen:
- Ceftriaxone 250 mg IM once 2
- PLUS Levofloxacin 500 mg orally once daily for 10 days OR Ofloxacin 300 mg orally twice daily for 10 days 2, 5
Men Over 35 Years (Enteric Organism Etiology)
Epididymitis in this age group is typically caused by enteric bacteria (predominantly E. coli) secondary to bladder outlet obstruction or urinary tract instrumentation. 3, 5
Recommended regimen:
- Levofloxacin 500 mg orally once daily for 10 days 5
- OR Ofloxacin 300 mg orally twice daily for 10 days 5
Recent evidence demonstrates fluoroquinolones have superior efficacy compared to beta-lactams in this population, with ciprofloxacin showing a 20% absolute risk reduction in treatment failure compared to pivampicillin. 6
Critical Diagnostic Considerations
Rule out testicular torsion first - this is a surgical emergency, particularly in adolescents. 3, 1 Emergency testing for torsion is indicated when pain onset is sudden and severe, or when initial testing does not confirm urethritis or urinary tract infection. 3, 1
Essential diagnostic workup:
- Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 3, 1
- Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis 3, 1
- First-void urine examination for leukocytes if urethral Gram stain is negative 1
- Urine culture and Gram stain for enteric bacteria 3
Adjunctive Therapy
All patients require supportive care:
- Bed rest until fever and local inflammation subside 3, 1, 2
- Scrotal elevation 3, 1, 2
- Analgesics for pain control 1, 2
Follow-Up and Red Flags
Reassess within 3 days if no clinical improvement occurs. 3, 1, 2 Failure to improve requires reevaluation of both diagnosis and therapy, with consideration of hospitalization. 3, 1
Persistent swelling and tenderness after completing antimicrobial therapy warrants evaluation for:
- Testicular cancer 3, 1
- Tuberculous or fungal epididymitis 3, 1
- Abscess formation 1
- Testicular infarction 1
Partner Management
For sexually transmitted epididymitis, all sexual partners within 60 days preceding symptom onset must be evaluated and treated. 1, 2 Patients should avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic. 3, 1, 2
Special Populations
HIV-Positive Patients
HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients. 3, 1, 2 However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients and should be considered if standard therapy fails. 3, 1, 2
Pediatric Patients (Under 14 Years)
In children younger than 14 years, reflux of urine into the ejaculatory ducts is the most common cause, and the etiology is largely unknown. 5 For boys with acute epididymitis who have no pyuria or positive urine culture, antibiotics are not indicated as the condition is self-limiting. 7 Only boys with documented pyuria require antibiotic therapy. 7
Common Pitfalls
Do not assume age-based etiology without clinical context. Recent molecular diagnostic studies show that sexually transmitted infections (particularly C. trachomatis) are not restricted to patients under 35 years and can occur across all age groups. 8 Additionally, bacterial pathogens can be identified in 88% of antibiotic-naive patients using comprehensive testing including 16S rDNA analysis. 8
Do not substitute lower doses of ceftriaxone. The effect of using the 125 mg dose recommended for uncomplicated gonorrhea is unknown for epididymitis treatment. 3