Initial Treatment for Epididymitis
The initial treatment for epididymitis is ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, which covers both Chlamydia trachomatis and Neisseria gonorrhoeae—the most common pathogens in sexually active men under 35 years. 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
Primary Regimen:
- Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 3, 1, 2
- This combination targets both N. gonorrhoeae and C. trachomatis, which account for the majority of cases in this age group 2, 4
- C. trachomatis is responsible for approximately two-thirds of "idiopathic" epididymitis cases in younger men 5
Special Population - Men Who Practice Insertive Anal Intercourse:
- Use ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
- This regimen covers enteric organisms (particularly E. coli) in addition to sexually transmitted pathogens 2, 4
Men Over 35 Years (Enteric Organism Etiology)
Primary Regimen:
- Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
- E. coli and other Gram-negative enteric organisms predominate in this age group, typically secondary to bladder outlet obstruction 3, 4, 5
- Fluoroquinolones alone provide adequate coverage without needing ceftriaxone 4
Critical Diagnostic Considerations Before Treatment
Rule Out Testicular Torsion First:
- Emergency evaluation is mandatory when pain onset is sudden and severe 1, 2
- Testicular torsion requires immediate surgical consultation as testicular viability is time-dependent 1
- This is especially critical in adolescents where torsion is more common 3
Confirm Urethritis/Infection:
- Gram-stained urethral smear showing ≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis 3, 1, 2
- Obtain nucleic acid amplification test or culture for N. gonorrhoeae and C. trachomatis 1, 2
- Examine first-void urine for leukocytes if urethral Gram stain is negative 1, 2
Adjunctive Measures
Supportive Care:
- Bed rest and scrotal elevation until fever and local inflammation subside 3, 1, 2
- Analgesics for pain control 1, 2
Follow-Up Requirements
Reassessment at 3 Days:
- If no improvement within 3 days, reevaluate both diagnosis and therapy 3, 1, 2
- Consider hospitalization for severe pain, fever, or concerns about medication compliance 2
Persistent Symptoms After Treatment:
- Evaluate for testicular cancer, tuberculous or fungal epididymitis, tumor, abscess, or infarction 3, 1, 2
Management of Sexual Partners
Partner Notification and Treatment:
- Refer all sexual partners from the 60 days preceding symptom onset for evaluation and treatment 1, 2
- Both patient and partners must complete therapy and be asymptomatic before resuming sexual activity 3, 1, 2
- This is critical to prevent reinfection and reduce transmission 3
Common Pitfalls to Avoid
Age-Based Assumptions:
- Do not assume STIs only occur in men under 35—C. trachomatis was found across age groups in recent studies 6
- However, the predominant pathogens still differ by age, justifying age-based empiric therapy 4, 5
Antibiotic Selection:
- Fluoroquinolones are contraindicated in persons ≤17 years of age 3
- In antimicrobially pretreated patients, bacterial susceptibility to fluoroquinolones drops to 42%, though group 3 cephalosporins maintain 67% susceptibility 6
Special Populations
HIV-Positive Patients:
- Use the same treatment regimen as HIV-negative patients for uncomplicated epididymitis 1, 2
- However, fungal and mycobacterial causes are more common in immunosuppressed patients and should be considered if standard therapy fails 1, 2
Cephalosporin or Tetracycline Allergy:
- Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days as alternative 2