Treatment of Epididymitis
For sexually active men under 35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Active)
- Standard regimen: Ceftriaxone 250 mg IM once 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 4, 5, 6
- The combination addresses both organisms empirically before culture results return 4
Men Who Practice Insertive Anal Intercourse
- Modified regimen: Ceftriaxone 250 mg IM once PLUS either levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
- This broader coverage accounts for enteric organisms (particularly E. coli) in addition to sexually transmitted infections 4, 5
Men Over 35 Years or With Urinary Tract Abnormalities
- Monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2
- Enteric Gram-negative bacteria (especially E. coli) predominate in this population, typically from bladder outlet obstruction causing urinary reflux 5, 6, 7
Patients Allergic to Cephalosporins/Tetracyclines
- Alternative: Ofloxacin 300 mg orally twice daily for 10 days 1
Critical Treatment Duration
- All epididymitis cases require a minimum 10-day treatment course 2, 3
- Shorter courses risk treatment failure and chronic complications 5
Essential Adjunctive Measures
- Bed rest, scrotal elevation, and analgesics until fever and local inflammation resolve 4, 1, 2
- These supportive measures significantly improve symptom resolution 4
Mandatory Follow-Up Protocol
- Reevaluate within 72 hours if symptoms fail to improve 1, 2
- Persistent swelling or tenderness after completing antibiotics requires comprehensive workup for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal infection 1
Sexual Partner Management
- Refer all sexual partners from the preceding 60 days for evaluation and treatment when STI-related epididymitis is confirmed or suspected 1, 2
- Patients must abstain from sexual intercourse until both they and their partners complete treatment and are asymptomatic 1, 2
- Failure to treat partners leads to reinfection, as female partners of men with C. trachomatis epididymitis frequently harbor the organism 6
Diagnostic Pitfalls to Avoid
Rule Out Testicular Torsion First
- Always consider testicular torsion as a surgical emergency, particularly in adolescents with sudden-onset severe pain 1, 2
- Emergency surgical consultation may be needed when clinical findings are ambiguous 4
Obtain Proper Diagnostic Testing
- Gram stain and culture/NAAT of urethral specimen for N. gonorrhoeae and C. trachomatis 4, 2
- First-void urine examination for leukocytes and Gram-negative bacteria 4, 2
- These tests guide partner notification and confirm appropriate antimicrobial coverage 4
Common Clinical Errors
Fluoroquinolone Monotherapy in Young Men
- Ciprofloxacin and other fluoroquinolones are inadequate for chlamydial infection 8
- Despite being commonly prescribed, quinolones miss C. trachomatis in two-thirds of "idiopathic" epididymitis cases in young men 6, 8
- Recent data shows bacterial susceptibility to fluoroquinolones exceeds 85% in antibiotic-naive patients but drops to only 42% in pretreated patients 7
Age-Based Assumptions About STIs
- STIs are not restricted to men under 35 years 7
- C. trachomatis can occur across all age groups, so sexual history matters more than age alone 7
Special Populations
HIV-Infected Patients
- Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 1, 2
- Consider fungi and mycobacteria in immunosuppressed patients with atypical presentations 1
Pediatric Patients Under 14 Years
- Focus on enteric organisms as reflux of urine into ejaculatory ducts is the primary mechanism 5
- Fluoroquinolones targeting enteric bacteria are recommended 2
Pregnant Partners
- Female partners require evaluation even if asymptomatic, as many harbor C. trachomatis and risk pelvic inflammatory disease 6