What is the recommended treatment for epididymitis?

Treatment for Epididymitis

Empiric antibiotic therapy should be initiated immediately before culture results are available, with regimen selection based primarily on patient age and sexual activity, as this approach prevents serious complications including infertility and chronic pain. 1

Age-Based Treatment Algorithm

Sexually Active Men Under 35 Years

For epididymitis most likely caused by gonococcal or chlamydial infection, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2

• This combination targets Chlamydia trachomatis and Neisseria gonorrhoeae, which are the predominant pathogens in this age group 3, 4
• C. trachomatis accounts for approximately two-thirds of previously "idiopathic" epididymitis cases in young men and is associated with oligospermia 4, 5
• The CDC guidelines consistently recommend this dual therapy across multiple iterations 1

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

• Enteric organisms (particularly E. coli) are more likely in this population due to sexually transmitted enteric infection 1, 3
• The fluoroquinolone component provides coverage for gram-negative enteric bacteria 1

Men Over 35 Years or Those with Enteric Organism Suspicion

Treat with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days as monotherapy. 1, 2

• Escherichia coli is the predominant pathogen in men over 35 years, typically associated with bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture 3, 4, 5
• Fluoroquinolone monotherapy provides adequate coverage for enteric organisms without requiring additional STI coverage 1
• Important caveat: Rising fluoroquinolone resistance in E. coli isolates may necessitate alternative antimicrobials in some regions 6

Patients with Cephalosporin or Tetracycline Allergies

Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Essential Adjunctive Measures

All patients require bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1

• These supportive measures are recommended as adjuncts to antimicrobial therapy in all CDC guidelines 1
• Adequate fluid intake should accompany doxycycline administration to reduce esophageal irritation risk 7

Critical Follow-Up Parameters

Reevaluate both diagnosis and therapy if no clinical improvement occurs within 3 days of treatment initiation. 1, 2

• Failure to improve warrants consideration of alternative diagnoses including testicular torsion, tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for these alternative diagnoses 1, 2
• Hospitalization should be considered when severe pain suggests alternative diagnoses (torsion, infarction, abscess) or when patients are febrile or potentially noncompliant 1, 2

Sexual Partner Management

Patients with confirmed or suspected sexually transmitted epididymitis must refer all sex partners from the preceding 60 days for evaluation and treatment. 1

• Partners should be treated even without confirmatory testing, as female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease 4, 5
• Patients must abstain from sexual intercourse until both they and their partners complete therapy and are symptom-free 1

Special Populations

HIV-Infected Patients

HIV-positive patients with uncomplicated epididymitis receive identical treatment regimens as HIV-negative patients. 1, 2

• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 1, 2
• Consider these atypical pathogens if standard therapy fails 1

Diagnostic Workup Before Treatment

Obtain urethral Gram stain (≥5 PMNs per oil immersion field indicates urethritis), culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis, first-void urine examination for leukocytes if urethral Gram stain negative, and syphilis serology with HIV testing. 1, 2

• These diagnostic tests guide partner notification efforts but should not delay empiric therapy 1
• Microbiologic confirmation assists in determining whether sexual partners require treatment 1