Antibiotic Treatment for Testicular Infections
For acute epididymitis/epididymo-orchitis in men under 35 years, use doxycycline 100 mg orally twice daily for at least 10 days to cover sexually transmitted pathogens (Chlamydia trachomatis, Neisseria gonorrhoeae); for men over 35 years or those with risk factors for enteric organisms, use levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice daily for 10 days. 1, 2, 3
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Pathogens Predominate)
First-line regimen:
- Doxycycline 100 mg orally twice daily for at least 10 days 1, 2, 3
- This targets Chlamydia trachomatis and Ureaplasma urealyticum, the most common pathogens in this age group 1
Alternative regimen when gonorrhea is suspected or confirmed:
- Ceftriaxone 1 g IM or IV single dose PLUS Azithromycin 1 g orally single dose 1, 4
- This dual therapy addresses both gonococcal and chlamydial coinfection 1, 4
Men Over 35 Years (Enteric Organisms Predominate)
First-line regimen:
- Levofloxacin 500 mg orally once daily for 10 days 1, 2
- OR Ofloxacin 300 mg orally twice daily for 10 days 1, 2
- Fluoroquinolones provide superior coverage against Enterobacterales, which are the primary pathogens in this age group 1, 5
Critical Diagnostic Considerations Before Treatment
Rule out testicular torsion immediately - this is a surgical emergency requiring urgent intervention, not antibiotics 2. Look for:
Assess for Fournier's gangrene - requires immediate IV broad-spectrum antibiotics and surgical debridement 1, 5. Red flags include:
- Fever with systemic toxicity 1, 5
- Extensive scrotal erythema or skin necrosis 1, 5
- Crepitus on examination 1
- Septic appearance 1, 6
Identify the likely pathogen based on patient factors:
- Age under 35 + sexually active = Chlamydia trachomatis, Neisseria gonorrhoeae 1, 2
- Age over 35 + urinary symptoms = Enterobacterales (E. coli, Klebsiella) 1, 2
- Recent urethral instrumentation = Enterobacterales 1
- Immunocompromised = consider atypical organisms including fungi, mycobacteria 5, 2
Treatment Duration and Monitoring
Minimum treatment duration is 10 days for epididymitis 2, 3. This is critical because:
- Shorter courses have higher failure rates 2
- The epididymis has relatively poor antibiotic penetration requiring prolonged therapy 2
- Failure to improve mandates surgical evaluation and consideration of abscess formation 6
- Worsening symptoms suggest incorrect pathogen coverage or development of complications 6, 2
Adjunctive Measures (Non-Negotiable)
- Bed rest and scrotal elevation until fever and inflammation subside 2
- NSAIDs for pain control 2
- Sexual abstinence until treatment completion and symptom resolution 2
- Partner evaluation and treatment if sexually transmitted pathogens identified 2
Special Clinical Scenarios
Syphilitic Orchitis (Rare but Important)
If syphilis serology is positive with testicular mass:
- Doxycycline 100 mg orally twice daily for 14 days (early syphilis) or 28 days (late syphilis) 3, 7
- This can avoid unnecessary orchiectomy in cases mimicking testicular malignancy 7
- Always check tumor markers (LDH, AFP, β-hCG) to exclude malignancy 7
Immunocompromised Patients
- Use the same initial regimen (doxycycline or fluoroquinolone) based on age 5, 2
- Maintain higher suspicion for treatment failure 5, 2
- Consider atypical pathogens (fungi, mycobacteria) if no response by 72 hours 5, 2
Common Pitfalls to Avoid
Do not use fluoroquinolones alone in men under 35 - this misses chlamydial infection, which is the most common pathogen in this age group and requires doxycycline or azithromycin 1, 2
Do not use doxycycline alone in men over 35 - enteric organisms predominate and are not adequately covered by doxycycline 5, 2
Do not stop antibiotics early even if symptoms improve - the 10-day minimum is essential to prevent relapse and chronic epididymitis 2, 3
Avoid ciprofloxacin for gonococcal coverage - widespread quinolone resistance in N. gonorrhoeae makes this unreliable 4