What is the recommended treatment for a sexually active male patient with epididymitis, bilateral pitting pedal edema, and facial swelling, suspected to be caused by Chlamydia trachomatis or Neisseria gonorrhoeae?

Treatment of Epididymitis in Sexually Active Males

Immediate Empiric Treatment

For a sexually active male with epididymitis suspected to be caused by Chlamydia trachomatis or Neisseria gonorrhoeae, treat immediately with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2

This regimen provides:

• Microbiologic cure of infection 1
• Improvement of signs and symptoms 1
• Prevention of transmission to sexual partners 1
• Decreased risk of complications including infertility and chronic pain 1, 3

Diagnostic Workup Before Treatment

While empiric therapy should be initiated immediately, obtain the following diagnostic tests 1, 2:

• Gram-stained smear of urethral exudate or intraurethral swab (≥5 polymorphonuclear leukocytes per oil immersion field confirms urethritis) 1, 2
• Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis from intraurethral 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 counseling/testing 1, 2

Age-Based Treatment Algorithm

For sexually active men under 35 years:

• Primary pathogens: C. trachomatis and N. gonorrhoeae 3, 4
• Treatment: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 5
• This age group accounts for two-thirds of cases being chlamydial in origin 4

For men over 35 years:

• Primary pathogens: Enteric gram-negative organisms (especially E. coli) secondary to bladder outlet obstruction 3, 4
• Treatment: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2

For men who practice insertive anal intercourse (any age):

• Primary pathogens: Enteric organisms in addition to STI pathogens 3
• Treatment: Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg twice daily for 10 days) 2, 3

Adjunctive Supportive Measures

All patients require 1, 2:

• Bed rest until fever and local inflammation subside
• Scrotal elevation
• Analgesics for pain control

Critical Follow-Up and Red Flags

Reevaluate within 3 days if no improvement occurs 1, 2:

• Failure to improve requires reassessment of both diagnosis and therapy 1
• Consider alternative diagnoses: testicular torsion (surgical emergency), tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2

Testicular torsion must be ruled out immediately, especially in adolescents or when 2:

• Pain onset is sudden and severe
• No evidence of inflammation or infection is present
• Emergency surgical consultation is mandatory as testicular viability may be compromised 2

Management of Sexual Partners

All sexual partners from the 60 days preceding symptom onset must be evaluated and treated 1, 2:

• Partners should receive treatment even if asymptomatic 1
• Patient should avoid sexual intercourse until both patient and all partners complete therapy and are symptom-free 1, 2
• Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease 4

Special Considerations for This Patient

The bilateral pitting pedal edema and facial swelling are NOT typical features of uncomplicated epididymitis and warrant additional evaluation:

• These findings suggest possible nephrotic syndrome, heart failure, or other systemic conditions
• However, the epididymitis treatment regimen remains unchanged 2
• HIV-positive patients receive the same treatment as HIV-negative patients 1, 2
• Immunosuppressed patients have higher risk of fungal and mycobacterial epididymitis 1, 2

Common Pitfalls to Avoid

• Do not delay treatment waiting for culture results—empiric therapy is mandatory 1
• Do not use fluoroquinolones alone in sexually active men under 35 years, as they do not adequately cover C. trachomatis 3, 6
• Do not miss testicular torsion—this is a surgical emergency requiring immediate specialist consultation 2
• Do not fail to treat sexual partners—this leads to reinfection and continued transmission 1, 4
• Do not stop antibiotics early—the full 10-day course of doxycycline is essential to prevent complications including infertility 5, 3, 4