Initial Treatment for Epididymo-Orchitis
For sexually active men under 35 years, give ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2, 3
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
Primary regimen:
- Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 4, 1, 2, 3
- This covers both Neisseria gonorrhoeae and Chlamydia trachomatis, the most common pathogens in this age group 2, 5
Special consideration for men who practice insertive anal intercourse:
- Use 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, 2
- This broader coverage addresses sexually transmitted Escherichia coli in addition to gonorrhea and chlamydia 2
Men Over 35 Years (Enteric Organism Etiology)
Primary regimen:
- Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 4, 1, 2
- Enteric gram-negative organisms are the typical pathogens in this age group, often related to bladder outlet obstruction 1, 5, 6
- Note: Rising fluoroquinolone resistance in E. coli is a growing concern, though these remain guideline-recommended first-line agents 6
Patients with Cephalosporin or Tetracycline Allergies
- Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 4, 2
Essential Adjunctive Measures
- Bed rest and scrotal elevation until fever and local inflammation subside 4, 1, 2
- Analgesics for pain control 4, 2
- Administer doxycycline with adequate fluids, food, or milk to reduce esophageal irritation risk 3
Diagnostic Workup Before Treatment
For men under 35 years:
- Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 4, 1, 2
- Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 4, 1, 2
- First-void urine examination for leukocytes if urethral Gram stain is negative 4, 1, 2
- Syphilis serology and HIV testing 4, 1, 2
For men over 35 years:
- Urine culture and Gram-stained smear for gram-negative bacteria 1
- Evaluate for bladder outlet obstruction (benign prostatic hyperplasia, urethral stricture) 5, 6
Critical Follow-Up Parameters
- Reevaluate within 3 days if no improvement occurs 4, 1, 2
- Failure to improve requires reconsideration of both diagnosis and treatment 4
- Persistent swelling or tenderness after completing antibiotics mandates comprehensive evaluation for tumor, abscess, testicular infarction, testicular cancer, tuberculosis, or fungal epididymitis 4, 1, 2
Management of Sexual Partners
- Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 4, 1, 2
- Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 4, 1, 2
Common Pitfalls to Avoid
Testicular torsion must be ruled out immediately, especially in adolescents or when pain onset is sudden and severe—this is a surgical emergency requiring immediate specialist consultation 1
Do not assume all cases require antibiotics without confirming pyuria or urethritis, as this guides appropriate pathogen coverage 1
In the UK, adherence to sexually transmitted infection testing guidelines is poor in primary care, with fewer than 3% of patients receiving chlamydia testing and only 18% receiving doxycycline 7. This represents suboptimal care that increases risk of infertility and chronic pain 5.
Special Populations
HIV-positive patients:
- Treat with the same regimens as HIV-negative patients for uncomplicated cases 4, 1, 2
- Consider fungi and mycobacteria as potential pathogens in immunosuppressed patients 4, 1, 2
Hospitalization indications: