What is the treatment for epididymitis in men, considering the cause and potential underlying urological conditions?

Treatment of Epididymitis

Treatment of epididymitis requires age-stratified antibiotic selection: men under 35 years with sexually transmitted epididymitis should receive ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days, while men over 35 years with enteric organism infection should receive a fluoroquinolone (levofloxacin 500 mg daily or ofloxacin 300 mg twice daily) for 10 days. 1, 2, 3

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

The most common pathogens in this age group are Chlamydia trachomatis and Neisseria gonorrhoeae, which cause sexually transmitted epididymitis typically accompanied by urethritis 1, 4.

Recommended regimen:

• Ceftriaxone 250 mg intramuscular as a single dose 1, 2
• PLUS doxycycline 100 mg orally twice daily for 10 days 1, 3

This dual therapy achieves microbiologic cure, improves symptoms, prevents transmission, and decreases complications including infertility and chronic pain 1.

Men Who Practice Insertive Anal Intercourse

Enteric organisms (particularly E. coli) are additional likely pathogens in this population 1, 2.

Recommended regimen:

• Ceftriaxone 250 mg intramuscular once 2
• PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 2, 4

Men Over 35 Years

Epididymitis in this age group is typically caused by Gram-negative enteric organisms (especially E. coli) associated with urinary tract infections, often secondary to bladder outlet obstruction or recent urologic instrumentation 1, 4, 5.

Recommended regimen:

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2, 4

Fluoroquinolone monotherapy is sufficient because it covers enteric pathogens without requiring additional coverage for sexually transmitted organisms 4.

Alternative Regimen (Allergies to Cephalosporins/Tetracyclines)

For patients with drug allergies or when enteric organisms are suspected:

• Ofloxacin 300 mg orally twice daily for 10 days 1

Adjunctive Supportive Measures

All patients require non-pharmacologic interventions until fever and local inflammation resolve 1, 2:

• Bed rest 1
• Scrotal elevation 1
• Analgesics 1

Critical Diagnostic Considerations Before Treatment

Rule Out Testicular Torsion First

Testicular torsion is a surgical emergency that must be excluded in all cases, particularly in adolescents and when pain onset is sudden and severe 1, 2. Emergency surgical consultation is mandatory if the diagnosis is questionable, as testicular viability may be compromised 1, 2.

Required Diagnostic Workup

Before initiating empiric therapy, obtain 1, 2:

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

Follow-Up and Treatment Failure

Reevaluate both diagnosis and therapy if no improvement occurs within 3 days 1, 2. This is a critical timepoint that should not be missed.

Persistent swelling and tenderness after completing antimicrobial therapy requires comprehensive evaluation for 1, 2:

• Testicular cancer
• Abscess
• Infarction
• Tuberculous or fungal epididymitis (especially in immunocompromised patients)
• Tumor

Management of Sexual Partners

For epididymitis caused by sexually transmitted organisms 1, 2:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 2
• Instruct patients to avoid sexual intercourse until both patient and partners complete therapy and are symptom-free 1

Special Populations

HIV-Infected Patients

HIV-positive patients with uncomplicated epididymitis should receive the same treatment regimens as HIV-negative patients 1, 2. However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients and should be considered if standard therapy fails 1, 2.

Hospitalization Criteria

Consider inpatient management when 1:

• Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess)
• Patient is febrile
• Concerns about medication compliance exist

Common Pitfalls to Avoid

• Do not delay treatment waiting for culture results—empiric therapy must be initiated immediately based on age and risk factors 1
• Do not undertreate sexually active men under 35—they require dual coverage for both gonorrhea and chlamydia, not fluoroquinolone monotherapy 1, 4
• Do not assume all cases are infectious—failure to improve warrants consideration of non-infectious etiologies including autoimmune disease and malignancy 6
• Do not forget partner notification—untreated partners lead to reinfection and continued transmission 1