What is the treatment for acute epididymitis?

From the Guidelines

The treatment of acute epididymitis should primarily involve empiric antibiotic therapy, with ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis, as recommended by the European Association of Urology guidelines 1.

Key Considerations

• For suspected bacterial epididymitis, empiric antibiotic therapy should be started immediately, considering the patient's age and risk factors for urinary tract pathogens.
• The choice of antibiotics should cover sexually transmitted infections like chlamydia and gonorrhea, as well as other potential pathogens.
• Pain management, including NSAIDs like ibuprofen, and supportive measures such as scrotal support and elevation, are also crucial in the treatment of acute epididymitis 1.

Treatment Approach

• The European Association of Urology guidelines suggest a single antibiotic or a combination of two antibiotics active against Chlamydia trachomatis and Enterobacterales 1.
• Consider parenteral therapy if the infection is severe, and ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis may be an appropriate option.
• Clinical assessment, midstream urine for culture, urethral swab/smear, and scrotal ultrasound examination may be necessary to guide treatment and diagnose potential complications.

Important Considerations

• The treatment approach should prioritize the patient's age, risk factors, and severity of symptoms.
• Prompt treatment is essential to prevent complications like abscess formation or infertility.
• Patients should abstain from sexual activity until treatment is complete, and follow-up is necessary to ensure complete resolution of symptoms.

From the FDA Drug Label

Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days The treatment for acute epididymitis is doxycycline (PO) 100 mg, by mouth, twice a day for at least 10 days 2.

• The dosage is the same for infections caused by N. gonorrhoeae or C. trachomatis.

From the Research

Treatment of Acute Epididymitis

• The treatment of acute epididymitis is based on the patient's age and the likely causative organisms 3.
• In sexually active males aged 14 to 35 years, the most common pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis, and the treatment of choice is a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline 3.
• In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen 3.
• In men older than 35 years, epididymitis is usually caused by enteric bacteria, and levofloxacin or ofloxacin alone is sufficient to treat these infections 3.
• The choice of antibiotic regimen is empirical and based on the most likely causative pathogen, whether sexually transmitted, enteric, or other 4.
• Recent advances in diagnostic techniques support a change in the management paradigm, and the use of advanced microbiology techniques can provide new insights that challenge traditional management paradigms 4.
• The 2021 CDC guidelines recommend a higher dose of ceftriaxone for gonorrhea and doxycycline as first-line therapy for chlamydia 5.
• Other studies have compared the effectiveness of different antibiotic regimens, such as ceftriaxone plus azithromycin versus ceftriaxone plus doxycycline, and found that the treatment regimen was not related to time to retreatment 6.
• The emergence of resistant strains to certain antibiotics is a concern, and new therapies such as short-term therapy with fluoroquinolones or azalides (e.g. azithromycin) are very effective and easy to use 7.