Treatment of Epididymo-Orchitis in Sexually Active Males
For sexually active men under 35 years presenting with epididymo-orchitis, treat immediately with ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Active)
The primary pathogens in this population are Chlamydia trachomatis and Neisseria gonorrhoeae, requiring dual antimicrobial coverage 2:
- Ceftriaxone 250 mg IM single dose 1, 2, 3
- PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2, 3
This regimen provides comprehensive coverage for both gonorrhea and chlamydia, which are the most common causative organisms in this age group 2, 4.
Men Over 35 Years
Enteric gram-negative organisms (particularly E. coli) are the primary pathogens, typically associated with urinary tract abnormalities such as benign prostatic hyperplasia or urethral stricture 1, 5:
- Levofloxacin 500 mg orally once daily for 10 days 1, 6
- OR Ofloxacin 300 mg orally twice daily for 10 days 1, 6
Essential Supportive Care
All patients require adjunctive therapy regardless of age 1, 2:
- Bed rest until fever and local inflammation subside 1, 6, 2
- Scrotal elevation using rolled towels or supportive underwear 1, 6
- Analgesics for pain control 1, 6, 2
Critical Diagnostic Steps Before Treatment
Rule Out Testicular Torsion First
Testicular torsion is a surgical emergency that must be excluded immediately, especially when 1, 6:
- Pain onset is sudden and severe 1, 6
- Patient is an adolescent or young adult 6
- No evidence of inflammation or infection is present 6
Confirm Infectious Etiology
Obtain diagnostic testing to guide therapy 1, 6:
- Urethral Gram stain looking for ≥5 polymorphonuclear leukocytes per oil immersion field 1, 6
- Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1, 6
- First-void urine examination for leukocytes if urethral Gram stain is negative 1, 6
- Urine culture and Gram stain for gram-negative bacteria in men over 35 1
Mandatory Follow-Up Protocol
Reassess within 72 hours if no clinical improvement occurs 1, 6, 2. Failure to improve requires reevaluation of both diagnosis and therapy 6, 2.
Alternative Diagnoses to Consider
If symptoms persist after 3 days of appropriate antimicrobial therapy, consider 1, 6:
- Testicular torsion
- Testicular tumor or cancer
- Testicular abscess
- Testicular infarction
- Tuberculosis
- Fungal epididymitis (especially in immunosuppressed patients) 1, 2
Sexual Partner Management
For sexually transmitted epididymo-orchitis 1, 2:
- Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 2
- Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 1, 2
Special Population Considerations
HIV-Positive Patients
HIV-positive patients with uncomplicated epididymo-orchitis receive the same treatment regimen as HIV-negative patients 1, 2. However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 1, 2.
Common Clinical Pitfalls
Never assume purely traumatic etiology without obtaining urethral swab or first-void urine for diagnostic testing 6. If any evidence of infection exists (fever, urethritis, or pyuria), treat as bacterial epididymo-orchitis, not as traumatic injury 6.
The presence of pyuria supports infectious etiology and indicates need for antimicrobial therapy 1. However, absence of pyuria does not exclude sexually transmitted epididymo-orchitis, as urethritis may still be present 1.
Rising fluoroquinolone resistance in E. coli isolates means alternative antimicrobials may be needed in some geographic areas for enteric organism coverage 5.