What is the treatment for acute orchitis?

Treatment of Acute Orchitis

For men under 35 years with acute orchitis, administer ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover sexually transmitted pathogens; for men over 35 years, use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days to target enteric organisms. 1, 2

Initial Diagnostic Approach

Before initiating treatment, confirm the diagnosis and rule out surgical emergencies:

• Perform ultrasound imaging to confirm orchitis and exclude testicular torsion, which requires emergency surgery 1
• Obtain urethral swab for Gram stain if urethritis is present 1
• Send nucleic acid amplification tests for N. gonorrhoeae and C. trachomatis 1
• Examine first-void urine for leukocytes and perform urine culture 1

The distinction between testicular torsion and orchitis is critical—torsion requires surgical intervention within 4-6 hours, while orchitis is managed medically 3.

Age-Based Antibiotic Selection

Men Under 35 Years (Sexually Transmitted Pathogens)

The most common causative organisms in this age group are Chlamydia trachomatis and Neisseria gonorrhoeae 1, 3:

• Ceftriaxone 250 mg IM as a single dose 1
• PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2

This dual therapy provides coverage against both gonococcal and chlamydial infections, which frequently co-exist 1.

Men Over 35 Years (Enteric Organisms)

In older men, enteric bacteria (particularly E. coli) are the predominant pathogens 1, 3:

• Ofloxacin 300 mg orally twice daily for 10 days 1
• OR levofloxacin 500 mg orally once daily for 10 days 1

Fluoroquinolones provide excellent coverage against gram-negative enteric organisms commonly associated with urinary tract infections 1.

Supportive Care Measures

All patients require symptomatic management alongside antibiotics 1:

• Bed rest until fever and inflammation subside 1
• Scrotal elevation to reduce swelling and pain 1
• Analgesics for pain control 1

Indications for Hospitalization

Consider admission for patients who meet any of these criteria 1:

• Severe pain suggesting alternative diagnoses requiring urgent evaluation 1
• Fever or systemic toxicity 1
• Anticipated non-compliance with oral antibiotic regimen 1
• Failure to improve within 48-72 hours of outpatient therapy 4

Surgical Intervention

Surgery is rarely needed but should be considered in specific circumstances 4:

• No clinical improvement after 48-72 hours of appropriate antibiotic therapy 4
• Presence of testicular abscess on imaging 4, 5
• Severe cases with tissue necrosis requiring debridement or orchiectomy 4, 5

In one study, 14.6% of patients with moderate disease (hydrocele with small abscesses) required organ-sparing surgery when conservative treatment failed 4.

Follow-Up and Treatment Failure

Reassess both diagnosis and therapy if no improvement occurs within 3 days of starting antibiotics 1:

• Consider alternative diagnoses: testicular tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal infection 1
• Persistent swelling after completing antibiotics warrants comprehensive re-evaluation including possible imaging and cultures 1
• For immunocompromised patients, consider fungal or mycobacterial causes requiring specialized therapy 1

Management of Sexual Partners

For orchitis caused by sexually transmitted infections 1:

• Refer sex partners for evaluation and treatment if contact occurred within 60 days before symptom onset 1
• Partners should receive empiric treatment for gonorrhea and chlamydia without waiting for test results 1
• Patients must abstain from sexual intercourse until both they and their partners complete treatment and are cured 1

Special Considerations

Viral Orchitis

Viral orchitis requires supportive care only—antibiotics are ineffective 1:

• Diagnose through IgM serology or acute/convalescent IgG titers 1
• Common viral causes include mumps, Coxsackie virus, rubella, Epstein-Barr virus, and varicella zoster 1, 6
• Treatment consists of rest, scrotal support, and analgesics 1

Immunocompromised Patients

These patients have higher risk of atypical pathogens 1:

• Fungal orchitis may require fluconazole as the agent of choice for Candida species 1
• Mycobacterial infections (tuberculosis) require specialized antimycobacterial therapy based on culture results 1
• Consider these diagnoses when standard antibiotic therapy fails 1

Autoimmune and Chronic Orchitis

Chronic asymptomatic orchitis with cellular infiltrates is found in approximately 25% of azoospermic men during testicular biopsy, though the etiopathogenesis remains unclear 6. This form is distinct from acute bacterial orchitis and may represent post-infectious or autoimmune processes 6.

Common Pitfalls

• Do not delay treatment while awaiting culture results—empiric therapy should begin immediately based on age and risk factors 1
• Beware of fluoroquinolone resistance, particularly in infections acquired in Asia or Pacific regions 7
• Always consider testicular torsion first in younger men with acute testicular pain—when in doubt, refer urgently 3
• Do not use monotherapy with clindamycin unless S. pneumoniae is confirmed, as it lacks activity against H. influenzae and M. catarrhalis 8