What is the treatment for orchiditis?

Treatment of Orchitis

Orchitis treatment is age-stratified and pathogen-directed: men under 35 require ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days targeting sexually transmitted organisms, while men over 35 require fluoroquinolone monotherapy (levofloxacin 500 mg daily or ofloxacin 300 mg twice daily for 10 days) targeting enteric bacteria. 1

Critical First Step: Rule Out Testicular Torsion

• Testicular torsion must be excluded immediately in all cases of acute testicular pain, particularly when onset is sudden, pain is severe, or the patient is an adolescent. 1
• If diagnosis is uncertain, consult a specialist immediately as testicular viability is compromised after 4-6 hours. 1, 2
• Torsion occurs more frequently in patients without evidence of inflammation or infection. 1

Diagnostic Workup Before Treatment

Obtain these studies to guide empiric therapy:

• Urethral Gram stain (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis). 1
• Nucleic acid amplification test on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis. 1
• First-void urine for leukocytes, culture, and Gram stain if urethral Gram stain is negative. 1
• Syphilis serology and HIV counseling/testing. 1

Age-Based Antibiotic Regimens

For Men Under 35 Years (Sexually Transmitted Pathogens)

Primary regimen targeting C. trachomatis and N. gonorrhoeae:

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

This combination provides microbiologic cure, symptom improvement, prevention of transmission, and decreased complications including infertility and chronic pain. 1

For Men Over 35 Years (Enteric Organisms)

Fluoroquinolone monotherapy targeting coliform bacteria:

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

Men over 35 more frequently have enteric organism infections associated with urinary tract instrumentation, surgery, or anatomical abnormalities. 1

Alternative for Cephalosporin/Tetracycline Allergies

• Use fluoroquinolone regimens (levofloxacin or ofloxacin) as listed above for any age group with drug allergies. 1

Essential Adjunctive Therapy

All patients require supportive measures until fever and inflammation subside:

• Bed rest 1, 2
• Scrotal elevation (using rolled towels or supportive underwear) 1, 2
• Analgesics for pain control 1, 2

Mandatory Follow-Up and Reassessment

• Patients must return within 3 days if no improvement occurs, as this requires reevaluation of both diagnosis and therapy. 1, 2
• Persistent swelling and tenderness after completing antibiotics warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis. 1

Management of Sexual Partners

For sexually transmitted cases (N. gonorrhoeae or C. trachomatis):

• Refer all sexual partners from the preceding 60 days for evaluation and treatment. 1
• Partners should receive treatment for the same pathogens as the index patient. 1
• Instruct patients to abstain from sexual intercourse until both patient and partners complete therapy and are asymptomatic. 1

Hospitalization Criteria

Consider inpatient management when:

• Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess). 1
• Patient is febrile. 1
• Concern exists about medication compliance. 1

Special Populations

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients for uncomplicated cases. 1
• Be aware that fungi and mycobacteria cause epididymo-orchitis more frequently in immunosuppressed patients. 1

Common Clinical Pitfalls

• Never conclude the etiology is purely traumatic without obtaining urethral swab or first-void urine testing. 2
• If any evidence of infection exists (fever, urethritis, pyuria), treat as bacterial epididymo-orchitis, not traumatic injury. 2
• Rising fluoroquinolone resistance in E. coli may necessitate alternative agents in the future for enteric organism coverage. 4
• Viral orchitis (especially mumps) can mimic testicular neoplasia clinically and radiographically but is managed conservatively. 5, 6