Treatment for Epididymitis
For men under 35 years with suspected sexually transmitted epididymitis, administer ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years with likely enteric bacterial infection, prescribe levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
- Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
- This covers both N. gonorrhoeae (57% of cases in this age group) and C. trachomatis (34% of cases) 3
- Sexually transmitted pathogens account for 78% of epididymitis cases in men under 35 3
Men Over 35 Years (Enteric Bacterial Etiology)
- Monotherapy with fluoroquinolones: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
- E. coli is the predominant pathogen (56% of all cases, 30% in older men) and is typically secondary to bladder outlet obstruction 4, 3
- Fluoroquinolones have >85% susceptibility rates against cultured bacteria in antibiotic-naive patients 4
Special Population: 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 twice daily for 10 days) 1, 5
- This covers both sexually transmitted pathogens and enteric organisms 5
Critical Diagnostic Steps Before Treatment
- Evaluate for urethritis: Gram-stained smear of urethral exudate showing ≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis 1
- Obtain cultures or NAAT: Test for N. gonorrhoeae and C. trachomatis via culture or nucleic acid amplification 1
- First-void urine analysis: Examine for leukocytes if urethral Gram stain is negative 1
- Additional screening: Syphilis serology and HIV counseling/testing are recommended 1
Adjunctive Supportive Measures
- Bed rest with scrotal elevation using rolled towel or supportive underwear until fever and local inflammation subside 1, 6
- Analgesics for pain management during the acute phase 1, 6
- Adequate fluid intake with doxycycline to reduce risk of esophageal irritation 2
Critical Follow-Up Requirements
- Reevaluate within 3 days if no improvement occurs, as this may indicate incorrect diagnosis or treatment failure 1, 6
- Persistent symptoms after completing antibiotics require comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1
- Prostate-specific antigen levels should halve within 3 months in successfully treated cases 4
Sexual Partner Management
- Refer all partners from the preceding 60 days for evaluation and treatment if STI-related epididymitis is suspected or confirmed 1, 6
- Abstain from sexual intercourse until both patient and partners complete treatment and are symptom-free 1, 6
- Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease (67% in one study) 7
Common Pitfalls to Avoid
- Do not assume age-based etiology is absolute: STIs are not restricted to men under 35 years and were found in 14% of all cases across age groups 4
- Rule out testicular torsion immediately: This surgical emergency requires immediate specialist consultation, especially when pain onset is sudden and severe 1, 6
- Complete the full 10-day antibiotic course even if symptoms improve earlier, as premature discontinuation leads to treatment failure and potential infertility 6, 5
- Do not use fluoroquinolone monotherapy in men under 35: This misses gonococcal coverage and contributes to treatment failure 1, 5