From the Guidelines
The treatment of epididymitis should primarily involve antibiotics, pain management, and supportive care, with the most recent guidelines recommending ceftriaxone 1000 mg i.m. or i.v. plus a course of an antibiotic active against Chlamydia trachomatis for severe infections, as outlined in the 2024 European Association of Urology guidelines 1. The goal of treatment is to achieve microbiologic cure of infection, improvement of signs and symptoms, prevention of transmission to others, and a decrease in potential complications such as infertility or chronic pain, as noted in the 2002 CDC guidelines 1. Key considerations in the treatment of epididymitis include:
- Antibiotic selection: The choice of antibiotic should be guided by the suspected cause of the infection, with ceftriaxone and doxycycline being commonly recommended options 1.
- Pain management: NSAIDs such as ibuprofen or naproxen can be used to manage pain and inflammation, with dosages of 400-600mg every 6-8 hours or 500mg twice daily, respectively.
- Supportive care: Bed rest, scrotal elevation, and application of cold packs can help reduce swelling and promote healing.
- Partner notification and treatment: If the condition is sexually transmitted, partners should be notified and treated to prevent further transmission. It is essential to note that symptoms typically improve within 48-72 hours of starting antibiotics, but complete resolution may take weeks. If symptoms worsen or don't improve after 72 hours of treatment, patients should seek further medical evaluation to rule out complications or alternative diagnoses.
From the FDA Drug Label
Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days The recommended treatment for epididymitis caused by N. gonorrhoeae or C. trachomatis is doxycycline (PO) 100 mg, by mouth, twice a day for at least 10 days 2.
- The dosage is the same for both N. gonorrhoeae and C. trachomatis infections.
- The treatment should be continued for at least 10 days.
From the Research
Treatment of Epididymitis
The treatment of epididymitis depends on the patient's age and the likely causative organisms.
- For sexually active males between 14 and 35 years of age, the most common pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis, and the treatment of choice is a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline 3, 4.
- In men who practice insertive anal intercourse, an enteric organism is also likely, and ceftriaxone with 10 days of oral levofloxacin or ofloxacin is the recommended treatment regimen 3.
- In men older than 35 years, epididymitis is usually caused by enteric bacteria, and levofloxacin or ofloxacin alone is sufficient to treat these infections 3.
- The choice of initial antibiotic regimen is empirical and based on the most likely causative pathogen, whether sexually transmitted, enteric, or other 5.
- Current treatment regimens remain empirical, although recent advances using modern diagnostic techniques support a change in the management paradigm 5.
Antibiotic Management
The use of advanced microbiology techniques and studies of current practice provide new insights that have challenged traditional management paradigms 5.
- Relatively sparse direct trial data exists on antimicrobial treatments for acute epididymitis, and much of the presently available guidance is derived from previous guidance recommendations, knowledge of antimicrobial activities of specific agents, and treatment outcomes in uncomplicated infections 5.
- Identification of specific pathogens and prescribing accuracy is dependent on the extent to which cases are investigated and is therefore variable 5.
- Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and Mycoplasma genitalium 6.