What is the initial treatment for orchiepididymitis (inflammation of the testicle and epididymis)?

Initial Treatment for Orchiepididymitis

The initial treatment for orchiepididymitis is ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days in sexually active men under 35 years, while men over 35 years should receive ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

Primary regimen:

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2
• This combination targets the most common pathogens in this age group: Chlamydia trachomatis and Neisseria gonorrhoeae 3, 4
• Doxycycline should be continued for the full 10-day course to ensure microbiologic cure and prevent complications such as infertility or chronic pain 3, 5

Alternative regimen:

• Ofloxacin 300 mg orally twice daily for 10 days (for patients allergic to cephalosporins or tetracyclines) 3, 1
• Note: Ofloxacin is contraindicated in patients ≤17 years of age 3

Men Over 35 Years (Enteric Organism Etiology)

Primary regimen:

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2, 4
• These fluoroquinolones effectively cover enteric Gram-negative organisms that cause epididymitis in this age group, typically associated with bladder outlet obstruction or urinary tract abnormalities 3, 6, 4

Important caveat: Rising fluoroquinolone resistance in E. coli isolates means alternative antimicrobials may be needed if resistance is suspected or documented 6

Critical Diagnostic Considerations Before Treatment

Rule Out Testicular Torsion First

• Testicular torsion is a surgical emergency that must be excluded in ALL cases, especially in adolescents 3, 1, 2
• Emergency consultation is indicated when pain onset is sudden, pain is severe, or initial testing does not confirm urethritis or urinary tract infection 3, 1
• Torsion occurs more frequently in patients without evidence of inflammation or infection 3

Diagnostic Workup to Perform

• Gram-stained smear of urethral exudate showing ≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis 3, 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 3, 1
• First-void urine examination for leukocytes if urethral Gram stain is negative 3, 1
• Syphilis serology and HIV counseling/testing 3, 1

Adjunctive Therapy (Essential for All Patients)

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 3, 1, 2
• These supportive measures are recommended as adjuncts to antimicrobial therapy in all treatment guidelines 3, 1

Follow-Up and Red Flags

When to Reevaluate

• Failure to improve within 3 days requires immediate reevaluation of both diagnosis and therapy 3, 1, 2
• Persistent swelling and tenderness after completing antimicrobial therapy warrants comprehensive evaluation 3, 1

Alternative Diagnoses to Consider

• Tumor, abscess, infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis 3, 1, 2
• These conditions become more likely when standard treatment fails 3

Sexual Partner Management

• Partners should be evaluated and treated if contact occurred within 60 days preceding symptom onset 3, 1, 2
• Patients must avoid sexual intercourse until both patient and partner(s) complete therapy and are symptom-free 3, 1
• This applies to all cases of suspected or confirmed sexually transmitted epididymitis 1

Special Populations

HIV-Positive Patients

• Receive the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 3, 1, 2
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 3, 1, 2

Men Who Practice Insertive Anal Intercourse

• Enteric organisms are more likely in this population 4
• Consider ceftriaxone with levofloxacin or ofloxacin to cover both sexually transmitted and enteric pathogens 4

Common Pitfalls to Avoid

• Do not delay treatment waiting for culture results—empiric therapy must be initiated immediately 3
• Do not use azithromycin as a substitute for doxycycline—the effect of this substitution is unknown for epididymitis 3
• Do not assume all cases require antibiotics—always rule out testicular torsion first, which requires surgical intervention, not antibiotics 1
• Do not use fluoroquinolones as first-line in men under 35—they do not adequately cover C. trachomatis compared to doxycycline 2, 4