What is the recommended treatment for a male patient with epididymitis, particularly for those under 35 and sexually active versus those over 35 or with suspected enteric organisms?

Treatment of Epididymitis

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days; for men over 35 years or those with suspected enteric organisms, treat with ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

The primary pathogens in this age group are sexually transmitted: Neisseria gonorrhoeae and Chlamydia trachomatis. 3, 4, 5

Recommended regimen:

• Ceftriaxone 250 mg IM as a single dose 3, 1, 2
• PLUS Doxycycline 100 mg orally twice daily for 10 days 3, 1, 6

This dual therapy provides coverage for both gonococcal and chlamydial infections, which are the most common causative organisms in sexually active younger men. 3, 4 The doxycycline component must be continued for the full 10-day course to ensure microbiologic cure and prevent complications such as infertility or chronic pain. 3, 6

Special consideration for men who practice insertive anal intercourse:

• Use ceftriaxone 250 mg IM once PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) to cover enteric organisms in addition to STI pathogens. 1, 2, 4

Men Over 35 Years or With Suspected Enteric Organisms

Epididymitis in this population is typically caused by Gram-negative enteric organisms (primarily E. coli) associated with urinary tract infections, often secondary to bladder outlet obstruction or anatomical abnormalities. 3, 4, 5

Recommended regimen:

• Ofloxacin 300 mg orally twice daily for 10 days 3, 1, 7
• OR Levofloxacin 500 mg orally once daily for 10 days 1, 2, 4

Fluoroquinolones provide excellent coverage for enteric pathogens and achieve good tissue penetration in the genitourinary tract. 7, 4 Monotherapy with a fluoroquinolone is sufficient in this age group when enteric organisms are suspected. 3, 4

Adjunctive Measures

Regardless of age or etiology, all patients should receive:

• Bed rest until fever and local inflammation subside 3, 1
• Scrotal elevation 3, 1
• Analgesics for pain management 3, 1

These supportive measures help reduce inflammation and improve patient comfort during the acute phase. 3

Critical Diagnostic Considerations Before Treatment

Rule Out Testicular Torsion First

Testicular torsion is a surgical emergency that must be excluded, particularly in adolescents and when pain onset is sudden and severe. 3, 1, 2 Emergency surgical consultation is required if torsion cannot be ruled out, as testicular viability is compromised after 4-6 hours. 1, 8

Diagnostic Workup

Before initiating empiric therapy, obtain:

• Gram-stained smear of urethral exudate or intraurethral swab (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 3, 1, 2
• Nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis 3, 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 3, 1, 2
• Urine culture and Gram-stained smear of uncentrifuged urine 3, 1
• Syphilis serology and HIV counseling/testing 3, 1

Hospitalization Criteria

Admit patients who have:

• Severe pain suggesting alternative diagnoses (torsion, testicular infarction, abscess) 3, 1
• Fever or systemic illness 3, 1, 8
• Anticipated noncompliance with oral antimicrobial regimen 3, 1

Follow-Up and Treatment Failure

Patients must show improvement within 3 days of starting treatment. 3, 1, 2 Failure to improve requires immediate reevaluation of both diagnosis and therapy. 3, 1

Persistent swelling and tenderness after completing antimicrobial therapy warrants comprehensive evaluation for:

• Testicular tumor 3, 1
• Abscess formation 3, 1
• Testicular infarction 3, 1
• Testicular cancer 1, 2
• Tuberculous or fungal epididymitis (especially in immunocompromised patients) 3, 1

Management of Sexual Partners

For STI-related epididymitis:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 3, 1, 2
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are symptom-free 3, 1, 2

This prevents reinfection and reduces transmission to others. 3

Special Populations

HIV-infected patients: Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis. 3, 1, 2

Immunocompromised patients: Consider fungal and mycobacterial causes more strongly in this population. 1, 2

Common Pitfalls to Avoid

• Do not delay treatment while awaiting culture results—empiric therapy should be initiated immediately based on age and risk factors. 3
• Do not undertreate younger patients—the full 10-day course of doxycycline is essential to prevent complications and ensure microbiologic cure. 3, 6
• Do not miss testicular torsion—maintain a high index of suspicion, especially when inflammation or infection markers are absent. 3, 1
• Do not forget partner notification—failure to treat sexual partners leads to reinfection and continued transmission. 3, 1