What is the treatment for orchitis?

Treatment for Orchitis

Age-Based Antibiotic Selection

For men under 35 years old with orchitis, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover sexually transmitted pathogens (Chlamydia trachomatis and Neisseria gonorrhoeae). 1

For men 35 years and older with orchitis, treat with either ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days to cover enteric organisms, particularly E. coli. 1

Rationale for Age-Based Treatment

• Men under 35 years predominantly develop orchitis from sexually transmitted infections, with C. trachomatis being the most common pathogen, followed by N. gonorrhoeae 2
• Men over 35 years typically have orchitis caused by enteric organisms (especially E. coli) associated with urinary tract abnormalities such as benign prostatic hyperplasia or urethral stricture 1, 3
• The age cutoff of 35 years is consistently used across CDC guidelines to stratify treatment approaches 1, 4

Essential Diagnostic Workup

Before initiating treatment, obtain:

• Gram-stained smear of urethral exudate to diagnose urethritis 1
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis - this is the most sensitive and specific test available 1
• First-void urine examination for leukocytes 1
• Urine culture to identify enteric pathogens, particularly in men ≥35 years 2
• Scrotal ultrasound to confirm orchitis diagnosis and rule out testicular torsion, which is a surgical emergency requiring immediate intervention 1, 5

Critical Pitfall to Avoid

Only 50% of men diagnosed with orchitis in emergency departments receive appropriate STI testing, leading to missed diagnoses and inadequate treatment 2. Always test for gonorrhea and chlamydia in men under 35, as 13.8% will test positive 2.

Supportive Care Measures

All patients require:

• Bed rest until fever and local inflammation subside 1, 5
• Scrotal elevation using athletic supporter or tight-fitting underwear 1, 5
• Analgesics (NSAIDs or acetaminophen) for pain control and inflammation reduction 5
• Ice packs applied to the scrotum for additional symptomatic relief 5

Hospitalization Criteria

Consider hospitalization when 1:

• Severe pain suggests alternative diagnoses (testicular torsion, abscess, tumor)
• Patient is febrile with systemic symptoms
• Concern exists about patient non-compliance with oral antimicrobial regimen

Viral Orchitis Management

For confirmed viral orchitis (diagnosed via IgM serology or acute/convalescent IgG serology):

• Supportive care only with bed rest, scrotal elevation, and analgesics 5
• Common viral causes include mumps virus, Coxsackie virus, rubella virus, Epstein-Barr virus, and varicella zoster virus 1, 5
• However, empiric antibiotics should still be given if bacterial etiology cannot be definitively excluded, using the age-based algorithm above 5

Viral Orchitis Prognosis

Mumps orchitis carries the highest risk of fertility complications, though complete sterility is rare 5.

Follow-Up and Treatment Failure

• Reevaluate within 3 days if no clinical improvement occurs, as this suggests incorrect diagnosis or treatment failure 1, 5
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for 1:
  • Testicular tumor
  • Abscess formation
  • Testicular infarction
  • Testicular cancer
  • Tuberculosis (especially in immunosuppressed patients)
  • Fungal epididymitis (especially in immunosuppressed patients)

Management of Sexual Partners

For orchitis caused by sexually transmitted infections:

• Refer all sexual partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset 1
• Patients must abstain from sexual intercourse until both they and their partners complete treatment (7 days after single-dose regimen or after completion of 7-day regimen) 1
• Partners should be treated for the same STDs identified in the index patient 1

Special Populations

Immunosuppressed Patients

• More likely to have fungal or mycobacterial causes of orchitis 1
• Consider tuberculosis and systemic fungal diseases in the differential diagnosis 1
• May require extended diagnostic workup including tissue biopsy if standard treatment fails

Rising Fluoroquinolone Resistance

While fluoroquinolones (ofloxacin, levofloxacin) remain guideline-recommended for men ≥35 years, rising ciprofloxacin resistance in E. coli isolates in Europe and the USA necessitates awareness of potential treatment failures 3. If no improvement occurs within 3 days, consider alternative antimicrobials based on culture sensitivities 1.