What is the best course of treatment for a patient presenting with epididymitis, characterized by a dull ache in the testicle?

Treatment of Epididymitis with Testicular Ache

For a patient presenting with a dull testicular ache from epididymitis, initiate empiric treatment immediately with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days, while simultaneously ruling out testicular torsion as a surgical emergency. 1, 2

Immediate Diagnostic Priorities

Rule out testicular torsion first – this is a surgical emergency that can mimic epididymitis but requires immediate specialist consultation, particularly when pain onset is sudden or severe. 3, 1 The cremasteric reflex should be intact in epididymitis but absent in torsion, and the testis should be in normal anatomic position. 4

Essential Diagnostic Workup

Before or concurrent with empiric treatment, obtain:

• Gram-stained smear of urethral exudate looking for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 3, 2
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis on intraurethral swab or first-void urine 3, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative 3, 1
• Urine culture and Gram stain to identify enteric organisms like E. coli 5, 6
• Syphilis serology and HIV testing 3, 2

Age-Based Treatment Algorithm

For Sexually Active Men Under 35 Years

Primary regimen (covers STIs):

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2
• This targets C. trachomatis (most common at 12.3%) and N. gonorrhoeae (3.1%) 6, 7

If patient practices insertive anal intercourse:

• Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days 5, 7
• This broader coverage includes enteric organisms transmitted during anal intercourse 7

For Men Over 35 Years or Non-STI Etiology

Primary regimen (covers enteric organisms):

• Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 3, 5, 7
• E. coli is the predominant pathogen (78% of positive cultures), followed by Klebsiella, Proteus, and Pseudomonas 6, 8

Alternative if STI cannot be excluded:

• Use the ceftriaxone plus doxycycline regimen to cover both STI and enteric pathogens 5

Critical Adjunctive Measures

All patients require:

• Bed rest with scrotal elevation using rolled towels or supportive underwear until fever and inflammation resolve 3, 5, 2
• Analgesics for pain control during acute inflammation 3, 2
• Avoid sexual intercourse until patient and partners complete treatment and are symptom-free 3, 2

Mandatory 72-Hour Reassessment

Failure to improve within 3 days mandates immediate reevaluation of both diagnosis and treatment. 3, 5, 2 At this point, consider:

• Alternative diagnoses: testicular tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 3, 1, 2
• Treatment failure: switch antibiotic regimen based on culture results 5
• Hospitalization if severe pain persists, patient is febrile, or compliance concerns exist 2

Persistent swelling and tenderness after completing the full antimicrobial course requires comprehensive urologic evaluation. 1, 2

Partner Management

Contact tracing is mandatory for STI-related cases:

• Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 3, 1, 2
• Partners should receive presumptive treatment for N. gonorrhoeae and C. trachomatis even before test results return 2

Special Populations

HIV-positive patients receive identical treatment regimens as HIV-negative patients for uncomplicated epididymitis, but fungi and mycobacteria are more likely causative organisms in immunosuppressed states. 3, 2

Patients allergic to cephalosporins or tetracyclines should receive fluoroquinolone monotherapy (levofloxacin 500 mg daily or ofloxacin 300 mg twice daily for 10 days). 3, 2

Common Pitfalls to Avoid

• Do not delay treatment waiting for culture results – empiric therapy prevents complications including infertility and chronic pain 3
• Do not undertreate STI-related epididymitis – only 50% of ED patients receive appropriate STI testing, missing 13.8% of positive cases 6
• Do not assume age predicts etiology – STIs occurred across all age groups in recent studies, not just under 35 years 8
• Do not miss testicular torsion – when in doubt, obtain immediate surgical consultation as testicular viability deteriorates rapidly 1, 5