What is the recommended treatment for suspected epididymitis?

Treatment for Suspected Epididymitis

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

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

• Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This targets the most common pathogens in this age group: N. gonorrhoeae and C. trachomatis, which account for the majority of cases 3, 4, 5
• Studies confirm these organisms are isolated from the urethra in two-thirds to three-quarters of young men with epididymitis 6, 5

Men Who Practice Insertive Anal Intercourse

• Modified regimen: 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 sexually transmitted pathogens 3, 4

Men Over 35 Years

• Monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2
• Enteric organisms, particularly E. coli, predominate in this age group, typically associated with bladder outlet obstruction or urinary tract abnormalities 3, 4, 6

Patients Allergic to Cephalosporins/Tetracyclines

• Alternative: Ofloxacin 300 mg orally twice daily for 10 days 1

Essential Adjunctive Measures

All patients require supportive care regardless of antimicrobial regimen:

• Bed rest until fever and local inflammation subside 3, 1, 2
• Scrotal elevation to reduce swelling and pain 3, 1, 2
• Analgesics for pain management 1, 2

Critical Diagnostic Considerations

Before initiating treatment, obtain:

• Gram-stained smear of urethral exudate or intraurethral swab to assess for N. gonorrhoeae and urethritis (≥5 polymorphonuclear leukocytes per oil immersion field) 3, 2
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis from intraurethral swab or first-void urine 2
• Urinalysis and urine culture for enteric organisms 3, 2
• Syphilis serology and HIV testing with counseling 2

Testicular torsion must be excluded immediately, particularly in adolescents, as this is a surgical emergency that presents with similar symptoms but requires urgent intervention rather than antibiotics 3, 1, 2

Follow-Up Protocol

• Reevaluate within 72 hours if symptoms do not improve after starting treatment 1, 2
• Persistent swelling or tenderness after completing the full antimicrobial course warrants comprehensive evaluation for alternative diagnoses including tumor, abscess, testicular cancer, tuberculosis, or fungal infection 1

Partner Management

For sexually transmitted epididymitis:

• Refer all sexual partners from the preceding 60 days for evaluation and empiric treatment 1, 2
• Patients must abstain from sexual intercourse until both they and their partners complete therapy and are asymptomatic 1, 2
• Untreated partners lead to reinfection and perpetuate transmission 3, 1
• Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease, even when asymptomatic 6, 7

Common Pitfalls

Urethritis is often asymptomatic in men with sexually transmitted epididymitis—53% of patients show inflammatory cells on urethral smear without visible discharge 5. Do not rely on the presence of urethral discharge to guide treatment decisions 3.

The minimum treatment duration is 10 days for all cases, regardless of etiology 2, 8. Shorter courses risk treatment failure and complications including chronic pain and infertility 4.

Rising fluoroquinolone resistance in E. coli is an emerging concern for older men with enteric epididymitis 9. If fluoroquinolone resistance is documented or suspected based on local antibiograms, alternative antimicrobials with adequate tissue penetration should be considered.

Special Populations

• HIV-infected patients: Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 1, 2
• Immunosuppressed patients: Consider fungi and mycobacteria as potential pathogens 1
• Pediatric patients under 14 years: Epididymitis is typically caused by reflux of urine into the ejaculatory ducts rather than infection; when infection is present, enteric organisms predominate 4