What is the recommended management for a patient presenting with a testicular infection, considering potential sexually transmitted infections (STIs) and underlying urological conditions?

Management of Testicular Infection

For testicular infections (epididymitis/orchitis), treat empirically with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days, as these regimens cover both sexually transmitted pathogens and enteric bacteria in this age group. 1

Initial Assessment and Pathogen Considerations

Rule out testicular torsion immediately - this is a surgical emergency requiring urgent intervention, not antibiotics. 1 Any acute scrotal pain with sudden onset warrants immediate surgical consultation.

The causative organisms depend critically on patient age:

• In men <35 years: Chlamydia trachomatis and Neisseria gonorrhoeae are the primary pathogens 2, 3
• In men ≥35 years: Enteric bacteria (Enterobacterales) predominate, though sexually transmitted organisms remain possible 1, 3
• In men aged 35-43 years: Both sexually transmitted organisms AND enteric bacteria must be covered 1

First-Line Treatment Regimens

Preferred Empiric Therapy (Covers Both STI and Enteric Pathogens)

Levofloxacin 500 mg orally once daily for 10 days 1, 4

OR

Ofloxacin 300 mg orally twice daily for 10 days 1, 4

These fluoroquinolone regimens provide broad coverage and are the CDC-recommended first-line therapy. 1

Alternative Regimen (When STI Strongly Suspected)

Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 4

This combination is appropriate when gonorrhea and chlamydia are the suspected pathogens, particularly in younger men or those with clear STI risk factors. 1

Diagnostic Testing

Before initiating treatment, obtain:

• Nucleic acid amplification tests (NAATs) for N. gonorrhoeae and C. trachomatis - these have sensitivities of 86.1-100% and specificities of 97.1-100% 5
• First-void urine for leukocyte esterase or microscopy (≥10 WBC per high-power field indicates urethritis) 6
• Serologic test for syphilis in all patients with suspected STI 6
• HIV testing should be offered 6

However, do not delay treatment while awaiting test results - initiate empiric therapy immediately. 6

Critical Management Points

Mandatory Reevaluation

Reassess the patient after 3 days of therapy to ensure clinical response. 1 If symptoms persist or worsen, consider:

• Treatment failure or resistant organisms
• Alternative diagnosis (abscess, tumor, torsion)
• Need for imaging or urologic consultation

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1
• Avoid sexual intercourse until treatment is completed AND symptoms have resolved 1, 7
• Administer adequate fluids with doxycycline to reduce esophageal irritation risk 4

Partner Management

All sexual partners within the preceding 60 days require evaluation and treatment, even if asymptomatic. 6, 7 This is critical because:

• 70% of chlamydia and gonorrhea infections are asymptomatic 5
• Untreated partners lead to reinfection
• Partner notification prevents ongoing transmission 6

Special Considerations

When Specific Pathogens Are Identified

For confirmed C. trachomatis:

• Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally twice daily for 7 days 6, 4, 8
• Extend to 10 days for epididymitis 4

For confirmed N. gonorrhoeae:

• Ceftriaxone 500 mg IM single dose (updated from 125 mg due to resistance concerns) 9
• Always add treatment for chlamydia if coinfection not excluded 9

For Mycoplasma genitalium (if persistent symptoms after standard therapy):

• Azithromycin 500 mg on day 1, then 250 mg daily on days 2-5 (93-99% cure rate) 7, 10
• Note: Single-dose azithromycin 1g has declining efficacy 10

Immunocompromised Patients

Patients with HIV or other immunosuppression may harbor atypical pathogens including fungi and mycobacteria - consider broader workup if standard therapy fails. 1

Common Pitfalls to Avoid

1. Do not use doxycycline monotherapy for suspected gonorrhea - resistance is common and cure rates are inadequate 9, 5

2. Do not rely on azithromycin for gonorrhea treatment - resistance has risen rapidly, with nearly 5% of isolates showing elevated MICs by 2018 9

3. Do not use fluoroquinolones for gonorrhea - widespread resistance makes them unreliable 9, 5

4. Do not assume treatment success without follow-up - persistent symptoms require culture and antimicrobial susceptibility testing 6

5. Do not forget that 53-100% of extragenital gonorrhea and chlamydia infections are asymptomatic - test all anatomic sites of exposure 5