What is the recommended treatment for a patient with epididymitis?

Epididymitis Treatment

Treat epididymitis with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days in sexually active men under 35 years, or with levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) in men over 35 years or those with enteric organism infection. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

• Primary regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2
• This targets N. gonorrhoeae and C. trachomatis, the most common pathogens in this age group 3, 4
• The doxycycline component must continue for the full 10 days to prevent complications including infertility and chronic pain 5, 4

Men Who Practice Insertive Anal Intercourse

• Modified regimen: 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 1, 2
• The fluoroquinolone component covers enteric organisms (E. coli) in addition to sexually transmitted pathogens 3, 4

Men Over 35 Years

• Monotherapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 3, 1, 2
• Enteric gram-negative organisms (predominantly E. coli) cause epididymitis in this age group, typically secondary to bladder outlet obstruction 3, 4, 6
• Fluoroquinolones demonstrate >85% susceptibility against cultured bacteria in antibiotic-naive patients 6

Essential Adjunctive Measures

All patients require:

• Bed rest until fever and local inflammation subside 3, 1, 2
• Scrotal elevation to reduce swelling and pain 3, 1, 2
• Analgesics for pain control 3, 1, 2

Critical Diagnostic Considerations Before Treatment

Rule Out Testicular Torsion First

• Testicular torsion is a surgical emergency that must be excluded in all cases, especially in adolescents 3, 1
• Emergency consultation is mandatory when pain onset is sudden and severe, or when urethritis/UTI cannot be confirmed 3, 1
• Torsion occurs more frequently in patients without evidence of inflammation or infection 3

Obtain These Tests Before Starting Antibiotics

• Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis) 3, 1
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis from intraurethral swab or first-void urine 3, 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 3, 1
• Syphilis serology and HIV testing with counseling 3, 1, 2

Follow-Up Requirements

Mandatory 3-Day Reassessment

• Reevaluate within 72 hours of starting treatment 1, 2
• Failure to improve within 3 days requires complete reassessment of both diagnosis and therapy 3, 1

Persistent Symptoms After Treatment Completion

• Swelling and tenderness persisting after completing the full antibiotic course demands comprehensive evaluation 3, 1
• Differential diagnosis includes: tumor, abscess, testicular infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis 3, 1

Sexual Partner Management

For STI-related epididymitis:

• Refer all sex partners from the preceding 60 days for evaluation and treatment 3, 1, 2
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are symptom-free 3, 1, 2

Special Populations

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 3, 1, 2
• Fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Pediatric Patients Under 14 Years

• Focus treatment on enteric organisms using fluoroquinolones 2
• Reflux of urine into ejaculatory ducts is the most common cause in this age group 4

Common Pitfalls to Avoid

Age-Based Treatment Errors

• Do not assume all men over 35 have enteric infections—recent data shows STIs (C. trachomatis) occur across all age groups, not just younger men 6
• However, STIs represent only 14% of cases overall, with E. coli accounting for 56% 6

Antibiotic Selection Mistakes

• Do not use doxycycline monotherapy—it lacks coverage for N. gonorrhoeae 3
• Do not use fluoroquinolone monotherapy in men under 35 unless they have documented enteric infection 3

Duration Errors

• Never treat for less than 10 days—this is the minimum duration for all epididymitis cases regardless of etiology 1, 2, 5

Hospitalization Indications

• Consider admission when severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess) 3
• Hospitalize febrile patients or those unlikely to comply with oral antimicrobial regimens 3