What is the treatment for orchitis?

Treatment for Orchitis

For men under 35 years with suspected sexually transmitted orchitis, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years with suspected enteric organism infection, treat with ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

Diagnostic Evaluation Before Treatment

Before initiating therapy, obtain the following:

• Gram-stained smear of urethral exudate to evaluate for urethritis 1
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis 1
• First-void urine examination for leukocytes, urinalysis, and urine culture 1
• Scrotal ultrasound to confirm the diagnosis and rule out testicular torsion, which requires emergency surgical intervention 1, 2

The ultrasound is critical because testicular torsion presents similarly but demands surgical exploration within 6-8 hours to prevent testicular loss 2.

Age-Stratified Treatment Approach

Men Under 35 Years (Sexually Transmitted Pathogens)

In this age group, Chlamydia trachomatis and Neisseria gonorrhoeae are the predominant pathogens 3, 4:

• Ceftriaxone 250 mg intramuscularly as a single dose 1
• PLUS doxycycline 100 mg orally twice daily for 10 days 1, 5

This dual therapy targets both gonorrhea and chlamydia, which frequently coexist 6, 3. Doxycycline should be taken with adequate fluids to reduce esophageal irritation risk 5.

Men Over 35 Years (Enteric Organisms)

In older men, coliform bacteria (particularly E. coli) are the primary pathogens, often associated with bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture 1, 7, 3:

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

Important caveat: Rising fluoroquinolone resistance in E. coli isolates means alternative antimicrobials may be needed if local resistance patterns are high 7. If urine culture reveals resistant organisms, adjust therapy based on susceptibility results 4.

Supportive Care Measures

All patients require adjunctive supportive therapy 1:

• Bed rest until fever and inflammation subside
• Scrotal elevation to reduce swelling and pain
• Analgesics for pain control
• Consider hospitalization if severe pain suggests alternative diagnoses (such as torsion or abscess), patient is febrile, or compliance with oral antibiotics is questionable 1

Follow-Up and Treatment Failure

• Reevaluate within 3 days if symptoms do not improve 1
• Comprehensive evaluation required for persistent swelling and tenderness after completing antimicrobial therapy 1
• Differential diagnosis for persistent symptoms includes testicular tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1

Failure to improve warrants reconsideration of the diagnosis and possible imaging with ultrasound to exclude complications 1.

Management of Sexual Partners

For orchitis caused by sexually transmitted infections 1:

• Refer sex partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset
• Patients should abstain from sexual intercourse until both they and their partners complete treatment and are cured
• Partners should receive empiric treatment for gonorrhea and chlamydia without waiting for test results 6

Special Considerations

Viral Orchitis

• Diagnosed through IgM serology or acute and convalescent IgG serology 1
• Common viral causes include mumps virus, Coxsackie virus, rubella virus, Epstein-Barr virus, and varicella zoster virus 1, 8
• Treatment is supportive only as antibiotics are ineffective for viral pathogens 8

Immunocompromised Patients

• Higher likelihood of fungal or mycobacterial causes including tuberculosis and systemic fungal diseases 1
• Requires specialized antifungal or antimycobacterial therapy based on culture results 6
• For Candida epididymo-orchitis, fluconazole is the agent of choice, though most patients require surgical drainage of abscesses in addition to antifungal therapy 6

Common Pitfalls to Avoid

• Do not assume age alone determines pathogen: While age-based guidelines are useful, obtain cultures when possible, as E. coli was found in 20% of urine cultures from men diagnosed with epididymo-orchitis across all ages 4
• Do not skip STI testing in men under 35: Only 50% of men diagnosed with epididymo-orchitis in emergency departments receive appropriate STI testing, yet 13.8% test positive 4
• Do not delay ultrasound when torsion is possible: Testicular torsion can present with similar symptoms but requires surgical intervention within 6-8 hours 2
• Do not use fluoroquinolones empirically in young men: This misses chlamydial infection, which requires doxycycline for adequate treatment 3, 9