What is the recommended treatment for a typical patient with epididymitis?

Treatment for Epididymitis

Recommended First-Line Treatment

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2 This regimen targets the most common pathogens in this age group: Chlamydia trachomatis and Neisseria gonorrhoeae. 2, 3

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

• Primary regimen: Ceftriaxone 250 mg IM once + doxycycline 100 mg PO twice daily for 10 days 4, 1, 2
• This combination provides coverage for both gonorrhea and chlamydia, which account for the majority of cases in this demographic 2, 3, 5
• For men who practice insertive anal intercourse: Use ceftriaxone 250 mg IM once + levofloxacin 500 mg PO daily for 10 days OR ofloxacin 300 mg PO twice daily for 10 days to cover enteric organisms 1, 2

Men Over 35 Years

• Primary regimen: Levofloxacin 500 mg PO once daily for 10 days OR ofloxacin 300 mg PO twice daily for 10 days 4, 1, 2
• Enteric gram-negative bacteria (predominantly E. coli) cause most cases in this age group due to urinary reflux from bladder outlet obstruction 2, 3, 5
• Fluoroquinolone monotherapy is sufficient as sexually transmitted infections are less common 3, 6

Alternative Regimens

For patients allergic to cephalosporins and/or tetracyclines: Ofloxacin 300 mg PO twice daily for 10 days OR levofloxacin 500 mg PO once daily for 10 days 4, 1, 2

Essential Adjunctive Measures

• Bed rest and scrotal elevation until fever and local inflammation resolve 4, 1, 2
• Analgesics for pain control 1, 2
• These supportive measures are critical for symptom relief and recovery 4

Diagnostic Workup Before Treatment

While empiric therapy should be initiated immediately, obtain the following tests to guide partner management and confirm diagnosis:

• Gram stain of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1, 2
• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 1, 2
• Syphilis serology and HIV testing 4, 1, 2

Critical Follow-Up Requirements

• Re-evaluate within 3 days if no clinical improvement occurs 4, 1, 2
• Failure to improve requires reassessment of both diagnosis and treatment 4
• Persistent swelling/tenderness after completing antibiotics warrants comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculous or fungal epididymitis 4, 1, 2

Management of Sexual Partners

• Refer all sexual partners who had contact within 60 days preceding symptom onset for evaluation and treatment 4, 1, 2
• Abstain from sexual intercourse until both patient and partner(s) complete therapy and are asymptomatic 4, 1, 2
• This prevents reinfection and reduces transmission 4

Special Populations

HIV-Positive Patients

• Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 4, 1, 2
• However, fungi and mycobacteria are more common causes in immunosuppressed patients 4, 1, 2
• Consider these atypical pathogens if standard therapy fails 1, 2

Critical Pitfalls to Avoid

Testicular Torsion Must Be Excluded

• Emergency evaluation for torsion is mandatory when pain onset is sudden and severe 4, 1
• Testicular torsion is a surgical emergency requiring immediate specialist consultation 1
• This is especially critical in adolescents where torsion is more frequent 4, 1

Don't Assume Age-Based Etiology

• Recent evidence shows STIs are not limited to patients under 35 years 6
• C. trachomatis was found in 14% of all cases across age groups in a modern diagnostic study 6
• Consider broader pathogen coverage if clinical suspicion warrants 6

Hospitalization Indications

• Severe pain suggesting alternative diagnoses 2
• Fever or systemic toxicity 2
• Concerns about medication compliance 2

Treatment Duration and Compliance

The 10-day treatment course is essential for both doxycycline and fluoroquinolone regimens 4, 1, 2, 7. Shorter courses risk treatment failure, chronic pain, and infertility 3. The FDA label confirms doxycycline 100 mg twice daily for at least 10 days for epididymo-orchitis caused by either N. gonorrhoeae or C. trachomatis 7.