What is the recommended treatment for epididymitis-orchitis?

Treatment for Epididymitis-Orchitis

For sexually active men under 35 years, 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 organisms, use levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

The primary pathogens in this age group are Chlamydia trachomatis and Neisseria gonorrhoeae. 2

Recommended regimen:

• Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2, 4
• This combination provides coverage for both gonorrhea and chlamydia 1, 2

Special consideration for men who practice insertive anal intercourse:

• Use ceftriaxone 250 mg IM once PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
• This regimen covers sexually transmitted E. coli in addition to gonorrhea and chlamydia 2, 5

Men Over 35 Years (Enteric Organism Etiology)

Epididymitis in this population is typically caused by enteric Gram-negative bacteria, often associated with bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture. 6, 5

Recommended regimen:

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2, 5
• Fluoroquinolones alone provide adequate coverage for enteric organisms 5

Important caveat: Rising ciprofloxacin resistance in E. coli isolates necessitates careful consideration of local resistance patterns. 6

Essential Diagnostic Workup Before Treatment

Empiric therapy should be initiated immediately, but obtain these tests to guide management: 1, 2

• Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 3, 1, 2
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 3, 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 1, 2
• Syphilis serology and HIV testing 1, 2

Adjunctive Measures

These supportive therapies should be implemented alongside antibiotics:

• Bed rest until fever and local inflammation subside 3, 1, 2
• Scrotal elevation 3, 1, 2
• Analgesics for pain control 1, 2

Critical Follow-Up Parameters

Reassess within 3 days if no improvement occurs. 3, 1, 2 Lack of response requires:

• Re-evaluation of the diagnosis (consider testicular torsion, tumor, abscess) 1, 2
• Consideration of hospitalization 2
• Evaluation for alternative diagnoses including testicular cancer, tuberculous or fungal epididymitis 3, 1, 2

Persistent swelling and tenderness after completing antimicrobial therapy mandates comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal infection. 1, 2

Management of Sexual Partners

For sexually transmitted cases:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 2
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 3, 1, 2

Alternative Regimens

For patients allergic to cephalosporins and/or tetracyclines:

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 3, 1, 2

Note: Ofloxacin is contraindicated in persons ≤17 years of age. 3

Special Populations

HIV-positive patients:

• Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 3, 1, 2
• Fungi and mycobacteria are more common causes in immunosuppressed patients and should be considered if standard therapy fails 3, 1, 2

Critical Pitfall: Testicular Torsion

Emergency testing for torsion is mandatory when pain onset is sudden and severe. 3, 1 Testicular torsion requires immediate specialist consultation as testicular viability may be compromised. 1 This is especially critical in adolescents where torsion is more frequent. 3

Indications for Hospitalization

Consider admission when: 2

• Severe pain suggests alternative diagnoses
• Patient is febrile
• Concerns exist about medication compliance