What is the initial workup and treatment for a patient presenting with epididymitis?

Initial Workup and Treatment for Epididymitis

For suspected epididymitis, immediately obtain urethral Gram stain and nucleic acid amplification testing for gonorrhea and chlamydia, then start empiric treatment with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days while ruling out testicular torsion. 1, 2

Critical First Step: Rule Out Testicular Torsion

• Testicular torsion is a surgical emergency that must be excluded in all cases, particularly in adolescents and when pain onset is sudden and severe 3, 1
• Emergency surgical consultation is mandatory if the diagnosis is uncertain, as testicular viability may be compromised 3, 1
• Torsion occurs more frequently in patients without evidence of inflammation or infection 3
• If test results during initial examination do not confirm urethritis or urinary tract infection, immediate expert consultation is required 3

Diagnostic Workup

Essential Laboratory Tests

• Gram-stained smear of urethral exudate or intraurethral swab: Look for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis and presumptively identify gonococcal infection 3, 1, 2
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 3, 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative; obtain culture and Gram-stained smear of uncentrifuged urine 3, 1
• Syphilis serology and HIV testing with appropriate counseling 3, 1, 2

Age-Based Etiology Considerations

• In sexually active men under 35 years: C. trachomatis and N. gonorrhoeae are the predominant pathogens 2, 4
• In men over 35 years: Enteric gram-negative organisms (predominantly E. coli) are most common, typically associated with bladder outlet obstruction 1, 4
• Sexually transmitted E. coli should be considered in men who are insertive partners during anal intercourse 2

Empiric Treatment Regimens

Standard Regimen (Most Patients)

Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2

• This regimen covers both gonococcal and chlamydial infections 3, 1
• Doxycycline should be continued for the full 10-day course even after symptoms improve 5
• Recent data shows this remains effective, with bacterial pathogens identified in 88% of antibiotic-naive patients 6

Alternative Regimen (Cephalosporin/Tetracycline Allergy)

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

• Fluoroquinolones alone are appropriate for men over 35 years with suspected enteric organisms 1, 4
• Susceptibility data shows >85% effectiveness against cultured bacteria in antibiotic-naive patients 6

Special Population: Men Who Practice Insertive Anal Intercourse

Ceftriaxone 250 mg IM once PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg twice daily for 10 days) 1, 4

• This regimen provides coverage for both sexually transmitted organisms and enteric pathogens 4

Adjunctive Measures

• Bed rest and scrotal elevation until fever and local inflammation subside 3, 1, 2
• Analgesics for pain control until symptoms resolve 3, 1, 2
• Adequate fluid intake with doxycycline to reduce risk of esophageal irritation 5
• Doxycycline may be given with food or milk if gastric irritation occurs 5

Follow-Up and Monitoring

• Reevaluate within 3 days if no improvement occurs; this requires reassessment of both diagnosis and therapy 3, 1, 2
• Persistent swelling or tenderness after completing antimicrobial therapy mandates comprehensive evaluation 3, 1, 2
• Differential diagnosis for treatment failure includes tumor, abscess, testicular infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis 3, 1, 2
• Prostate-specific antigen levels should normalize (halve) within 3 months in successfully treated cases 6

Management of Sexual Partners

• All sexual partners from the 60 days preceding symptom onset must be referred for evaluation and treatment 3, 1, 2
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 3, 1, 2
• This is critical because STI-related epididymitis is not limited to men under 35 years—it can occur at any age 6

Special Considerations

HIV-Positive Patients

• Uncomplicated epididymitis in HIV-positive patients requires the same treatment regimen as HIV-negative patients 3, 1, 2
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 3, 1, 2

Indications for Hospitalization

• Severe pain suggesting alternative diagnoses 2
• Fever or systemic toxicity 2
• Concerns about medication compliance 2
• Scrotal fixation over the involved testicle, which indicates actual or impending epididymal suppuration and potential testicular ischemia 7

Common Pitfalls to Avoid

• Do not assume all epididymitis in men over 35 is non-STI related: Recent molecular diagnostics show STIs occur across all age groups 6
• Do not delay treatment waiting for culture results: Empiric therapy must be initiated immediately to prevent complications including infertility and chronic pain 3, 2
• Do not discontinue antibiotics early: The full 10-day course is essential even if symptoms improve rapidly 3, 5
• Do not miss testicular torsion: When pyuria is absent and pain onset is sudden, torsion must be ruled out emergently 1
• Viral epididymitis is rare (found in only 1% of cases), so antibacterial therapy should not be withheld 6