What is the recommended treatment for epididymorchitis?

Treatment for Epididymo-Orchitis

Age-Based Treatment Algorithm

For sexually active men ages 14-35 years, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2

This dual therapy targets the most common pathogens in this age group—Chlamydia trachomatis and Neisseria gonorrhoeae—which account for the majority of sexually transmitted epididymo-orchitis cases. 2, 3

Treatment by Age and Risk Factors:

Men under 35 years (sexually active):

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 4, 1, 2
• This regimen provides coverage for both gonorrhea and chlamydia, the predominant organisms in this population 2, 3

Men who practice insertive anal intercourse:

• 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, 3
• The fluoroquinolone component covers enteric organisms that are more likely in this population 1, 3

Men over 35 years or enteric organism infection:

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days as monotherapy 4, 1, 3
• Enteric bacteria (primarily E. coli) transported by urinary reflux secondary to bladder outlet obstruction are the typical pathogens in this age group 5, 3

Essential Adjunctive Therapy

All patients require bed rest, scrotal elevation, and analgesics until fever and local inflammation resolve. 4, 1, 2

These supportive measures are critical components of treatment and should not be overlooked, as they significantly improve patient comfort and potentially reduce complications. 1, 2

Critical Follow-Up Requirements

Reevaluate all patients within 72 hours (3 days) of initiating treatment. 1, 2

• Failure to improve within 3 days mandates reevaluation of both the diagnosis and therapy 4, 2
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for alternative diagnoses including tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 4

Diagnostic Workup Before Treatment

Before initiating empiric therapy, obtain the following tests to guide treatment and identify sexually transmitted infections requiring partner notification: 1

• Gram-stained smear of urethral exudate or intraurethral swab (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 4, 1
• Nucleic acid amplification test (NAAT) or culture of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 4, 1
• First-void uncentrifuged urine examination for leukocytes if urethral Gram stain is negative, with culture and Gram stain 4, 1
• Syphilis serology and HIV testing with appropriate counseling 4, 1

Partner Management

For sexually transmitted epididymo-orchitis, all sexual partners within 60 days preceding symptom onset must be evaluated and treated. 4, 1, 2

• Patients must avoid all sexual intercourse until both they and their partners complete therapy and are asymptomatic 4, 1, 2
• This applies to cases known or suspected to be caused by N. gonorrhoeae or C. trachomatis 4, 2

Special Populations

HIV-positive patients with uncomplicated epididymo-orchitis receive the same treatment regimen as HIV-negative patients. 4, 1, 2

However, be aware that fungi and mycobacteria are more likely causative organisms in immunosuppressed patients compared to immunocompetent individuals. 4, 2, 6

Pediatric patients under 14 years:

• Treatment should focus on enteric organisms with fluoroquinolones 1
• Reflux of urine into the ejaculatory ducts is considered the most common cause in this age group 3

Treatment Duration

The minimum treatment duration for all epididymo-orchitis cases is 10 days. 1, 2, 7

This applies regardless of the causative organism or patient age group. 1, 7

Common Pitfalls and Caveats

Critical differential diagnosis: Acute testicular torsion must be excluded, especially in adolescents and when onset is sudden with severe pain. 4

• Torsion is a surgical emergency requiring intervention within 4-6 hours 5
• Torsion occurs more frequently in patients without evidence of inflammation or infection 4
• If diagnosis is questionable, consult a urologist immediately 4

Rising fluoroquinolone resistance: Ciprofloxacin resistance in E. coli isolates is increasing in Europe and the USA, necessitating consideration of alternative antimicrobials for enteric organism coverage. 8

Underlying urological pathology in older men: Men over 35 with epididymo-orchitis often have functional bladder outlet problems such as benign prostatic hyperplasia or urethral stricture disease. 8, 5

• Examine the abdomen for palpable bladder and perform digital rectal exam to assess for BPH, prostate cancer, constipation, or prostatitis 5