What is the treatment for epididymitis orchitis?

Treatment for Epididymitis-Orchitis

The initial treatment for epididymitis-orchitis is ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, which should be started empirically before culture results are available. 1, 2

Diagnostic Evaluation Before Treatment

Before initiating therapy, perform the following diagnostic workup:

• Gram-stained smear of urethral exudate or intraurethral swab to diagnose urethritis (≥5 polymorphonuclear leukocytes per oil immersion field) and presumptively identify gonococcal infection 3, 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 3, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 1, 2
• Syphilis serology and HIV testing should be performed 3, 2

Critical pitfall: Testicular torsion must be ruled out immediately, especially in adolescents or when pain onset is sudden and severe, as this is a surgical emergency that can compromise testicular viability 1, 2

Primary Treatment Regimen

Standard Empiric Therapy

For sexually transmitted epididymitis (most common in men under 35 years):

• Ceftriaxone 250 mg IM single dose 3, 1, 2
• PLUS Doxycycline 100 mg orally twice daily for 10 days 3, 1, 4

This regimen covers both C. trachomatis and N. gonorrhoeae, which are the most common pathogens in sexually active men 2

Alternative Regimens

For enteric organism-related epididymitis (more common in men over 35 years with urinary tract abnormalities) or patients allergic to cephalosporins/tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days 3, 1
• OR Levofloxacin 500 mg orally once daily for 10 days 1, 2

Important caveat: Rising fluoroquinolone resistance in E. coli isolates means these alternatives should be used judiciously, particularly when susceptibility data are available 5

Adjunctive Measures

All patients require supportive care:

• Bed rest and scrotal elevation until fever and local inflammation subside 3, 1, 2
• Analgesics for pain control 3, 2

Follow-Up and Treatment Failure

Reevaluate within 3 days if no clinical improvement occurs 1, 2. Failure to improve requires reassessment of both diagnosis and therapy 3

Persistent swelling or tenderness after completing antimicrobial therapy warrants comprehensive evaluation for:

• Tumor
• Abscess
• Testicular infarction
• Testicular cancer
• Tuberculous or fungal epididymitis 3, 1, 2

Management of Sexual Partners

All sexual partners from the 60 days preceding symptom onset should be referred for evaluation and treatment if epididymitis is known or suspected to be caused by N. gonorrhoeae or C. trachomatis 3, 1, 2

Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 3, 2

Special Populations

HIV-Positive Patients

HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients 3, 1, 2

However, fungi and mycobacteria are more likely causes in immunosuppressed patients and should be considered if standard therapy fails 3, 2

Hospitalization Indications

Consider hospitalization when:

• Severe pain suggests alternative diagnoses 2
• Patient is febrile 2
• Concerns about medication compliance exist 2

Patients with Indwelling Catheters

These patients are at high risk for multidrug-resistant organisms and should receive empiric treatment with both a fluoroquinolone and third-generation cephalosporin until susceptibility testing is complete 6