Treatment of Epididymitis-Orchitis
For sexually active men aged 14-35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia. 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
Standard regimen for most patients:
- Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 3
- This targets Neisseria gonorrhoeae and Chlamydia trachomatis, the most common pathogens in this age group 1, 4, 5
For men who practice insertive anal intercourse:
- Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days 2
- Alternative: Ceftriaxone 250 mg IM PLUS ofloxacin 300 mg orally twice daily for 10 days 2
- The fluoroquinolone component provides coverage for enteric organisms in addition to STI pathogens 2, 4
Men Over 35 Years (Enteric Organism Etiology)
Monotherapy with fluoroquinolone:
- Levofloxacin 500 mg orally once daily for 10 days 1, 2
- Alternative: Ofloxacin 300 mg orally twice daily for 10 days 1, 2
- E. coli is the predominant pathogen in this age group, typically associated with bladder outlet obstruction 4, 6
Important caveat: Rising fluoroquinolone resistance in E. coli isolates may necessitate alternative antimicrobials in some regions 7
Patients with Cephalosporin or Tetracycline Allergies
- Levofloxacin 500 mg orally once daily for 10 days 1
- Alternative: Ofloxacin 300 mg orally twice daily for 10 days 1
Essential Adjunctive Measures
All patients require:
- Bed rest until fever and local inflammation subside 1, 2
- Scrotal elevation until fever and local inflammation subside 1, 2
- Analgesics for pain control 1, 2
Diagnostic Testing Before Treatment
Obtain these tests to guide therapy, but do not delay empiric treatment:
- Gram-stained smear of urethral exudate or intraurethral swab (>5 PMNs per oil immersion field indicates urethritis) 1, 2
- Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis from intraurethral swab or first-void urine 1, 2
- First-void urine examination for leukocytes with culture and Gram stain if urethral smear is negative 1, 2
- Syphilis serology and HIV testing with counseling 1, 2
Critical pitfall: Only 50% of men diagnosed with epididymitis-orchitis in emergency departments receive appropriate STI testing, yet 13.8% test positive 6
Follow-Up and Treatment Failure
Mandatory reassessment at 72 hours:
- Failure to improve within 3 days requires complete reevaluation of diagnosis and therapy 1, 2
- Consider alternative diagnoses: testicular torsion, tumor, abscess, infarction, testicular cancer, tuberculous or fungal epididymitis 1
Persistent symptoms after completing antibiotics warrant investigation for:
- Testicular cancer 1
- Tuberculous epididymitis 1
- Fungal epididymitis (especially in immunocompromised patients) 1
- Abscess formation 1
Sexual Partner Management
For confirmed or suspected STI-related cases:
- Refer all sex partners from the preceding 60 days for evaluation and treatment 1, 2
- Patient must avoid sexual intercourse until both patient and all partners complete therapy and are asymptomatic 1, 2
Special Populations
HIV-infected patients:
- Use the same treatment regimens as HIV-negative patients 1, 2
- Maintain higher suspicion for fungal and mycobacterial causes in immunosuppressed patients 1, 2
Pediatric patients under 14 years:
- Focus treatment on enteric organisms with fluoroquinolones 2
- Reflux of urine into ejaculatory ducts is the most common etiology in this age group 4