What is the initial treatment for a sexually active patient presenting with epididimo-orchitis?

Treatment of Epididymo-Orchitis in Sexually Active Patients

For sexually active men under 35 years presenting with epididymo-orchitis, initiate empirical treatment with ceftriaxone 1g IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

Initial Empirical Treatment Algorithm

For Sexually Active Men <35 Years (STI-Related)

The most recent UK BASHH 2020 guideline recommends:

• Ceftriaxone 1g IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1
• This higher ceftriaxone dose (1g vs. the older 250mg recommendation) ensures effective treatment of gonorrhea strains with reduced susceptibility 1

The older CDC guidelines recommended ceftriaxone 250mg, but the 2020 BASHH guideline represents the most current evidence-based approach 2, 3

Alternative Regimen (If Gonorrhea Unlikely)

If microscopy shows no gram-negative intracellular diplococci OR no risk factors for gonorrhea are identified:

• Ofloxacin 300 mg orally twice daily for 10 days 2, 3, 1
• OR Levofloxacin 500 mg orally once daily for 10 days 2, 3
• OR Doxycycline alone 1

For Men >35 Years or Enteric Organism Suspicion

When enteric pathogens are likely (older age, not sexually active, recent urinary instrumentation, insertive anal intercourse, urinary tract abnormalities, or positive urine dipstick for leukocytes/nitrites):

• Ofloxacin 300 mg orally twice daily for 10 days 2, 3, 1
• OR Levofloxacin 500 mg orally once daily for 10 days 2, 3, 1

Important caveat: Rising fluoroquinolone resistance in E. coli means alternative antimicrobials may be needed in areas with high resistance rates 4

Essential Diagnostic Workup Before Treatment

Obtain these tests while initiating empirical therapy:

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

If Mycoplasma genitalium is tested and identified, include moxifloxacin in the treatment regimen 1

Adjunctive Supportive Measures

All patients require:

• Bed rest until fever and inflammation subside 2, 3
• Scrotal elevation 2, 3
• Analgesics 2, 3

Critical Follow-Up and Red Flags

Reevaluate within 3 days if no clinical improvement occurs 2, 3, 5

Persistent swelling/tenderness after completing antibiotics requires comprehensive evaluation for:

• Testicular tumor 2, 3
• Abscess 2, 3
• Testicular infarction 2, 3
• Testicular cancer 2, 3
• Tuberculous or fungal epididymitis 2, 3

Testicular Torsion Must Be Excluded

Emergency surgical consultation is mandatory when:

• Pain onset is sudden and severe 2, 3
• No evidence of inflammation or infection on initial testing 2, 3
• Diagnosis remains uncertain 2, 3

Testicular torsion occurs more frequently in adolescents and requires immediate intervention to preserve testicular viability 2, 3

Sexual Partner Management

All sexual partners from the 60 days preceding symptom onset must be evaluated and treated 2, 3

Patients must avoid sexual intercourse until both they and their partners complete treatment and are symptom-free 2, 3

Special Populations

HIV-infected patients receive the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 2, 3

However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients 2, 3