What is the recommended treatment regimen for epididymitis/orchitis?

Treatment Regimen for Epididymitis/Orchitis

The treatment regimen for epididymitis/orchitis is determined by patient age and sexual risk factors: men under 35 years require ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days, while men over 35 years are treated with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days as monotherapy. 1, 2

Age-Based Treatment Algorithm

Men Ages 14-35 Years (Sexually Active)

• Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 3
• This targets the most common pathogens in this age group: Chlamydia trachomatis and Neisseria gonorrhoeae 2, 4
• The 10-day minimum duration is mandatory regardless of clinical improvement 1, 2

Men Who Practice Insertive Anal Intercourse

• Modified regimen: 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, 2
• This provides enhanced coverage for enteric organisms such as E. coli that are more likely in this population 2, 4

Men Over 35 Years

• Fluoroquinolone monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
• Enteric bacteria, particularly E. coli, are the predominant pathogens in this age group, typically related to bladder outlet obstruction 2, 4
• No ceftriaxone is needed unless there are specific risk factors for sexually transmitted infections 5

Essential Diagnostic Testing Before Treatment

While empiric therapy should be initiated immediately, obtain the following tests to guide partner management and confirm diagnosis:

• Urethral evaluation: Gram-stained smear of urethral exudate or intraurethral swab specimen (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 5, 1
• Pathogen identification: Nucleic acid amplification test (NAAT) or culture of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1, 2
• Urine analysis: First-void uncentrifuged urine examination for leukocytes with culture and Gram stain if urethral Gram stain is negative 1, 2
• Additional screening: Syphilis serology and HIV testing with appropriate counseling 1, 2

Mandatory Adjunctive Therapy

All patients require non-pharmacologic measures until fever and local inflammation subside:

• Bed rest until systemic symptoms resolve 1, 2
• Scrotal elevation to reduce swelling and pain 5
• Analgesics for pain control 1, 2

Critical Follow-Up Requirements

• 72-hour reassessment: Reevaluate all patients within 3 days of initiating treatment 1, 2
• Failure to improve within 3 days mandates complete reassessment of both diagnosis and therapy 5, 2
• Persistent symptoms after completing antimicrobials require comprehensive evaluation for alternative diagnoses including tumor, abscess, infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis 5, 2

Partner Management and Sexual Activity Restrictions

• Partner notification: Refer all sex partners from the preceding 60 days for evaluation and treatment if N. gonorrhoeae or C. trachomatis is confirmed or suspected 1, 2
• Sexual abstinence: Patients must avoid all sexual intercourse until both they and their partners complete therapy and are completely asymptomatic 1, 2

Special Populations

HIV-Infected or Immunocompromised Patients

• Use the same treatment regimens as HIV-negative patients 1, 2
• Maintain higher clinical suspicion for fungal and mycobacterial causes, which are more common in immunosuppressed individuals 5, 2

Pediatric Patients Under 14 Years

• Focus treatment on enteric organisms using fluoroquinolones 1, 2
• Reflux of urine into the ejaculatory ducts is the most common etiology in this age group 4

Common Pitfalls and Caveats

• Never delay treatment waiting for culture results; empiric therapy must be initiated immediately 5
• Do not assume isolated orchitis: Bacterial orchitis typically represents extension from epididymitis, so always treat as epididymo-orchitis 2
• Avoid undertreating: The minimum 10-day duration applies to all cases regardless of rapid clinical improvement 1, 2
• Consider testicular torsion first: In patients with sudden onset of severe pain, especially adolescents, testicular torsion must be ruled out emergently as it is a surgical emergency 5, 6
• Recognize treatment failure early: Lack of improvement within 72 hours indicates either wrong diagnosis or inadequate antimicrobial coverage 1, 2