What is the recommended treatment for epididymitis?

Treatment of Epididymitis

For men under 35 years with suspected sexually transmitted epididymitis, administer ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years with likely enteric bacterial infection, treat with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

• Standard regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This covers both Neisseria gonorrhoeae and Chlamydia trachomatis, which account for the majority of cases in this age group 3, 4
• Research confirms that sexually transmitted pathogens (N. gonorrhoeae and/or C. trachomatis) are detected in up to 78% of patients under 35 years 4

Men Who Practice Insertive Anal Intercourse

• Modified regimen: Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) 1, 3
• The fluoroquinolone substitution provides coverage for enteric organisms in addition to sexually transmitted pathogens 3

Men Over 35 Years (Enteric Bacterial Etiology)

• Fluoroquinolone monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1
• Enteric gram-negative organisms, predominantly Escherichia coli, cause epididymitis in this age group secondary to bladder outlet obstruction and urinary reflux 1, 3
• Recent microbiologic data confirms that cultured bacteria remain susceptible to fluoroquinolones in over 85% of antibiotic-naive cases 5

Essential Diagnostic Workup

• Evaluate for urethritis: Gram-stained smear of urethral exudate showing ≥5 polymorphonuclear leukocytes per oil immersion field 1
• Pathogen detection: Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
• Urine analysis: First-void urine examination for leukocytes if urethral Gram stain is negative 1
• Additional screening: Syphilis serology and HIV counseling/testing 1

Critical Supportive Measures

• Bed rest with scrotal elevation using rolled towel or supportive underwear until fever and local inflammation subside 1, 6
• Analgesics for pain management during the acute phase 1, 6
• Complete the full 10-day antibiotic course even if symptoms improve earlier, as premature discontinuation leads to treatment failure 6

Management Pitfalls and Red Flags

Testicular Torsion Must Be Excluded

• Immediate specialist consultation required if pain onset is sudden and severe, as testicular viability may be compromised 1, 6
• Torsion is a surgical emergency particularly in adolescents and requires emergency testing when suspected 1

Reassessment at 3 Days

• Reevaluation is mandatory if no improvement occurs within 3 days of treatment initiation 1, 6
• Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1

Sexual Partner Management

• All partners from the preceding 60 days must be referred for evaluation and treatment if sexually transmitted infection is suspected or confirmed 1, 6
• Abstain from sexual intercourse until both patient and partners complete treatment and are symptom-free 1, 6

Special Populations

• HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients 1, 6
• Immunosuppressed patients have higher likelihood of fungal and mycobacterial causes requiring different diagnostic and therapeutic approaches 1, 6

Evidence Quality Considerations

The age-based treatment algorithm is supported by contemporary microbiologic studies using molecular diagnostics, which demonstrate that bacterial pathogens are identified in 88% of antibiotic-naive patients, with E. coli predominating (56%) overall but sexually transmitted infections accounting for 14% of cases across all age groups 5. Importantly, sexually transmitted infections are not restricted to patients under 35 years, though they remain most common in this demographic 5. The guideline recommendations align with FDA-approved dosing for doxycycline in acute epididymo-orchitis caused by both N. gonorrhoeae and C. trachomatis 2.