Initial Treatment of Epididymo-Orchitis in a 14-Year-Old
A 14-year-old with epididymo-orchitis should receive ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, as sexually transmitted pathogens (Chlamydia trachomatis and Neisseria gonorrhoeae) are the primary causes in this age group. 1, 2
Critical First Step: Rule Out Testicular Torsion
Before initiating antibiotic therapy, testicular torsion must be immediately excluded, particularly in adolescents where this surgical emergency is most common 2, 3. Key differentiating features include:
- Sudden, severe pain onset suggests torsion rather than epididymitis 2
- Absent cremasteric reflex indicates torsion; an intact reflex supports epididymitis 4
- Gradual pain onset with urinary symptoms (dysuria, frequency) points toward infectious epididymitis 4
If any doubt exists about torsion, obtain immediate urologic consultation before starting antibiotics 2, 3.
Diagnostic Workup Before Treatment
Obtain these studies to confirm diagnosis and guide therapy:
- Urethral Gram stain looking for ≥5 polymorphonuclear leukocytes per oil immersion field, indicating urethritis 5, 2
- Nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine 5, 2
- First-void urine examination for leukocytes if urethral Gram stain is negative 5, 2
- Syphilis serology and HIV testing as part of comprehensive STI screening 5, 2
Empiric Antibiotic Regimen
Do not wait for culture results—start treatment immediately after diagnostic specimens are collected 5, 1:
Standard Regimen for Age 14-35 Years:
- Ceftriaxone 250 mg IM (single dose) 5, 1, 2
- PLUS Doxycycline 100 mg orally twice daily for 10 days 5, 1, 2, 6
This combination targets both gonococcal and chlamydial infections, which account for the majority of cases in sexually active adolescents and young adults 4, 7.
Dosing Considerations for Adolescents:
For children weighing less than 100 pounds, doxycycline dosing is 2 mg/lb divided into two doses on day 1, then 1 mg/lb daily (or divided twice daily) for subsequent days 6. However, most 14-year-olds weigh over 100 pounds and receive the standard adult dose 6.
Adjunctive Supportive Care
Implement these measures until fever and inflammation resolve 5, 1:
- Bed rest to reduce scrotal movement and pain 5, 1, 3
- Scrotal elevation using rolled towels or supportive underwear 5, 1, 3
- Analgesics for pain control 5, 1, 3
Mandatory 72-Hour Reassessment
If no improvement occurs within 3 days, reevaluate both diagnosis and treatment 5, 1, 2. Failure to respond requires consideration of:
- Testicular torsion (delayed presentation) 2, 3
- Abscess formation requiring surgical drainage 2, 8
- Testicular tumor 5, 2
- Tuberculosis or fungal infection (especially if immunocompromised) 5, 2
- Incorrect pathogen coverage 5
Sexual Activity and Partner Management
Absolute sexual abstinence is required until both the patient and all partners complete treatment and are symptom-free 5, 1, 2. This is non-negotiable to prevent:
All sexual partners from the preceding 60 days must be evaluated and treated, even if asymptomatic 5, 1, 2. This is critical because:
- Asymptomatic carriage of gonorrhea and chlamydia is common 5
- Untreated partners will reinfect the patient 1
- Partner notification prevents community transmission 2
Common Pitfalls to Avoid
Do not assume trauma-only etiology even if there is a history of scrotal injury—always obtain urethral/urine testing before concluding the cause is purely traumatic 3. Any evidence of urethritis, pyuria, or fever indicates bacterial infection requiring antibiotics 3.
Do not stop antibiotics early when symptoms improve—the full 10-day course is essential to prevent chronic complications including infertility and chronic pain 5, 1. Only 50% of men with epididymo-orchitis receive appropriate STI testing in emergency settings, representing a major quality gap 7.
Do not use fluoroquinolones (levofloxacin, ofloxacin) in this age group—these are reserved for men over 35 years where enteric organisms predominate 5, 1, 2. In adolescents and young adults, STI pathogens are the primary concern 4, 7.
Special Considerations for Adolescents
Adolescents require confidential sexual history and counseling about:
- STI prevention strategies 5
- Condom use 1
- Partner notification obligations 2
- Risk of complications from untreated infection 1
The presence of STI-related epididymitis in a 14-year-old necessitates age-appropriate discussion about sexual activity, consent, and potential need for social services evaluation depending on partner age and circumstances.