What is the treatment for orchitis?

Treatment for Orchitis

For men under 35 years, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years, treat with ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Age-Based Treatment Algorithm

The treatment approach depends critically on patient age, as this determines the most likely causative pathogens:

Men Under 35 Years (Sexually Transmitted Pathogens)

• Primary regimen: Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This targets Neisseria gonorrhoeae and Chlamydia trachomatis, which are the predominant pathogens in this age group 1, 3, 4
• Chlamydia is more common than gonorrhea in men under 35 with orchitis (12.3% vs 3.1%) 3

Men Over 35 Years (Enteric Organisms)

• Primary regimen: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 5
• This targets enteric organisms, particularly E. coli, which is the most common pathogen in this age group 1, 5, 3
• Critical pitfall: Do NOT use doxycycline alone in men over 35, as it inadequately covers enteric organisms 5

Essential Diagnostic Workup Before Treatment

• Ultrasound is mandatory to rule out testicular torsion, which is a surgical emergency requiring immediate intervention 1
• Obtain Gram-stained smear of urethral exudate if urethritis is present 1
• Perform nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis 1
• Order urinalysis and urine culture to identify causative organisms, particularly in men over 35 5
• Examine first-void urine for leukocytes 1

Supportive Care Measures

All patients require adjunctive therapy regardless of antimicrobial choice:

• Bed rest until fever and local inflammation resolve 1, 5
• Scrotal elevation to reduce swelling 1, 5
• Analgesics for pain management 1, 5

Indications for Hospitalization

Consider admission for:

• Severe pain suggesting alternative diagnoses (abscess, torsion) 1, 5
• Fever or systemic toxicity 1, 5
• Concerns about medication non-compliance 1, 5
• Lack of clinical improvement within 48-72 hours of conservative treatment 6

Follow-Up and Treatment Failure

• Reevaluate within 3 days if no clinical improvement occurs 1, 5
• For persistent swelling and tenderness after completing antibiotics, perform comprehensive evaluation for:
  • Testicular tumor or cancer 1
  • Abscess formation 1, 6
  • Testicular infarction 1
  • Tuberculosis or fungal epididymitis 1
• Patients without palpable differentiation between epididymis and testis, with malacia or multiple abscesses, often require surgical intervention 6

Special Populations and Etiologies

Viral Orchitis

• Diagnosed through IgM serology or acute/convalescent IgG serology 1
• Common viral causes include mumps, Coxsackie virus, rubella, Epstein-Barr virus, and varicella zoster 1, 7
• Antibiotics are ineffective for viral orchitis; treatment is supportive only 1

Immunosuppressed Patients

• More likely to have fungal or mycobacterial causes 1
• Consider tuberculosis and systemic fungal diseases in the differential 1

Granulomatous Orchitis

• Antibiotics and steroids are ineffective 8
• Orchiectomy should be actively pursued for definitive treatment 8

Management of Sexual Partners

• Refer sex partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset when STIs are suspected 1
• Patients must avoid sexual intercourse until both they and their partners complete treatment 1

Critical Testing Gaps in Practice

• Only 50.1% of men diagnosed with orchitis receive testing for gonorrhea and chlamydia in emergency departments 3
• Only 62.1% receive urine culture 3
• Do not delay empiric treatment while awaiting culture results, but ensure appropriate testing is obtained 5