What is the treatment for epididymitis?

Treatment for Epididymitis

The initial treatment for epididymitis is ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, which covers both sexually transmitted and common bacterial pathogens. 1

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days is the standard regimen, targeting Chlamydia trachomatis and Neisseria gonorrhoeae as the most common pathogens 1, 2
• This combination provides dual coverage because sexually transmitted infections are the predominant cause in this age group 1
• For men who practice insertive anal intercourse, use 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) to cover sexually transmitted E. coli and other enteric organisms 1, 2

Men Over 35 Years

• Levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) as monotherapy is sufficient, targeting enteric gram-negative organisms associated with bladder outlet obstruction 1, 2
• Enteric bacteria, predominantly E. coli, cause epididymitis in this age group through urinary reflux into the ejaculatory ducts 2
• A critical caveat: rising fluoroquinolone resistance in E. coli isolates means susceptibility testing should guide therapy when possible 3

Alternative Regimens for Allergies

• 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 1
• These fluoroquinolones provide coverage for both sexually transmitted and enteric pathogens 1

Adjunctive Measures (Critical for Symptom Relief)

• Bed rest and scrotal elevation until fever and local inflammation subside 1
• Analgesics should be administered for pain control until symptoms improve 1
• These supportive measures are essential components of treatment, not optional 4

Follow-Up Requirements

• Reevaluate within 3 days if symptoms do not improve - failure to respond requires reassessment of both diagnosis and antimicrobial choice 1
• Persistent swelling or tenderness after completing the full antimicrobial course mandates comprehensive evaluation for alternative diagnoses including testicular tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 1

Management of Sexual Partners

• Refer all sexual partners for evaluation and treatment if contact occurred within 60 days preceding symptom onset in cases of suspected or confirmed sexually transmitted epididymitis 1
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 1
• This prevents reinfection and transmission, which can lead to treatment failure 4

Diagnostic Considerations Before Treatment

• Perform Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1
• Obtain culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 1
• Check first-void urine for leukocytes if urethral Gram stain is negative 1
• Perform syphilis serology and offer HIV testing in all cases of suspected sexually transmitted epididymitis 1

Special Populations

HIV-Positive Patients

• Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 1
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients, requiring broader diagnostic consideration 1

Hospitalization Criteria

• Consider hospitalization when severe pain suggests alternative diagnoses (especially testicular torsion), patient is febrile, or concerns about medication compliance exist 1
• Testicular torsion is a surgical emergency that must be ruled out, particularly in adolescents and when pain onset is sudden and severe 5

Critical Pitfalls to Avoid

• Never delay treatment while awaiting culture results - epididymitis requires immediate empirical therapy to prevent complications including infertility and chronic scrotal pain 2
• Do not assume all cases in men >35 years are non-sexually transmitted - recent data shows STIs (particularly C. trachomatis) are not restricted to younger age groups and were found in 14% of cases across all ages 6
• Always rule out testicular torsion first - this surgical emergency presents with similar symptoms but requires immediate specialist consultation, not antibiotics 5
• Recognize that approximately 30% of cases remain idiopathic despite comprehensive testing, but this should not delay empirical antimicrobial therapy 6