What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For sexually active men ages 14-35 years, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

Age-Based Treatment Algorithm

The treatment approach depends critically on patient age and sexual activity, as the causative organisms differ substantially:

Men Ages 14-35 Years (Sexually Active)

• Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 2, 1
• This combination targets Chlamydia trachomatis and Neisseria gonorrhoeae, which account for the majority of cases in this age group 3, 4
• C. trachomatis is particularly important as it causes two-thirds of previously "idiopathic" epididymitis cases and can lead to oligozoospermia if untreated 4

Men Who Practice Insertive Anal Intercourse

• Modified regimen: 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
• The fluoroquinolone component provides coverage for enteric organisms (E. coli) that can cause epididymitis in this population 2

Men Over 35 Years or With Urinary Tract Abnormalities

• Monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2, 1
• Enteric organisms, particularly E. coli, predominate in this age group due to urinary reflux from bladder outlet obstruction 3, 4
• Fluoroquinolone monotherapy provides adequate coverage without needing ceftriaxone 5

Critical Diagnostic Steps Before Treatment

Obtain these tests to guide therapy and identify partners requiring treatment:

• Gram-stained smear of urethral exudate or intraurethral swab to diagnose urethritis (≥5 polymorphonuclear leukocytes per oil immersion field) 2, 1
• Nucleic acid amplification test (NAAT) or culture of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
• First-void uncentrifuged urine examination for leukocytes if urethral Gram stain is negative, with culture and Gram stain 2, 1
• Syphilis serology and HIV testing with appropriate counseling 2, 1

Essential Adjunctive Therapy

All patients require non-pharmacologic measures until fever and inflammation resolve:

• Bed rest 2, 1
• Scrotal elevation 2, 1
• Analgesics 2, 1

Mandatory Follow-Up and Red Flags

• Reevaluate within 72 hours of initiating treatment 1
• Failure to improve within 3 days requires reassessment of both diagnosis and therapy 2
• Persistent swelling and tenderness after completing antibiotics warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 2, 1

Partner Management Requirements

For cases caused by or suspected to be N. gonorrhoeae or C. trachomatis:

• Refer all sex partners from the preceding 60 days for evaluation and treatment 2, 1
• Instruct patients to avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 2, 1
• Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease requiring treatment 4

Common Pitfalls to Avoid

Do not use ciprofloxacin monotherapy in young sexually active men. While fluoroquinolones are commonly prescribed (71% of urologists in one study), ciprofloxacin lacks adequate coverage for C. trachomatis, the predominant pathogen in this age group 6. This represents a significant deviation from evidence-based guidelines and can lead to treatment failure and infertility 6.

Do not assume STIs only occur in men under 35. Recent molecular diagnostic studies show that sexually transmitted infections, particularly C. trachomatis, are not restricted to younger age groups and can occur across all ages 5.

The minimum treatment duration is 10 days for all cases, regardless of regimen chosen 1, 7. Shorter courses risk treatment failure and complications including chronic pain and infertility 3.

Special Populations

• HIV-infected patients: Use the same treatment regimens as HIV-negative patients, though fungi and mycobacteria are more likely causes in immunosuppressed individuals 2, 1
• Pediatric patients under 14 years: Focus treatment on enteric organisms with fluoroquinolones, as reflux of urine into ejaculatory ducts is the most common etiology 1, 3