Epididymitis Workup and Treatment
Immediate Diagnostic Priorities
The workup must first exclude testicular torsion, particularly in adolescents and when pain onset is sudden and severe, as this is a surgical emergency requiring immediate specialist consultation. 1, 2
Essential Diagnostic Tests
Perform the following evaluations before initiating treatment:
Gram-stained smear of urethral exudate or intraurethral swab looking for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis and presumptively identify gonococcal infection 1, 2
Nucleic acid amplification test (NAAT) or culture of intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1, 2
First-void uncentrifuged urine examination for leukocytes if urethral Gram stain is negative, with culture and Gram stain for Gram-negative bacteria 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
Treat empirically with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2, 3, 4
This regimen covers N. gonorrhoeae and C. trachomatis, which are the predominant pathogens in this age group. 1, 4, 5
For 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) to cover enteric organisms. 2, 6, 4
Men Over 35 Years (Enteric Organism Etiology)
Treat with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1, 2, 6, 4
Enteric Gram-negative organisms, particularly E. coli, predominate in this age group due to urinary reflux from bladder outlet obstruction. 1, 4, 5
Critical Exception to Age-Based Treatment
Do not rely solely on age cutoffs—recent molecular diagnostic studies show that sexually transmitted infections occur in 14% of all cases and are not restricted to men under 35 years. 5 If urethritis is documented or STI risk factors are present in older men, treat as sexually transmitted epididymitis regardless of age.
Adjunctive Therapy
All patients require bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1, 2, 6
Follow-Up Requirements
Patients must be reevaluated if no improvement occurs within 3 days of treatment initiation. 1, 2, 6 Failure to improve requires reconsideration of the diagnosis and therapy.
Persistent swelling and tenderness after completing antimicrobial therapy mandates comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis. 1, 2
Management of Sexual Partners
Partners of patients with confirmed or suspected STI-related epididymitis must be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset. 1, 2
Patients should avoid sexual intercourse until both they and their partners complete treatment and are symptom-free. 1, 2
Common Pitfalls to Avoid
Never assume traumatic etiology without obtaining urethral swab or first-void urine for testing—if any evidence of infection exists (fever, urethritis, pyuria), treat as bacterial epididymo-orchitis. 6
Do not withhold antibiotics in prepubertal children reflexively—while bacterial infection is uncommon (4% positive urine cultures), urine cultures should be sent on all pediatric patients, and antibiotics reserved for young infants and those with pyuria or positive cultures. 7
Avoid assuming all cases in men over 35 are non-STI related—molecular diagnostics reveal STIs across all age groups. 5
Special Populations
HIV-infected patients should receive the same treatment regimen as HIV-negative patients, though fungi and mycobacteria are more likely causes in immunosuppressed individuals. 1, 2
Pregnant partners of men with epididymitis require special consideration for partner treatment and should be referred appropriately. 1