Treatment of Epididymitis
Treat epididymitis based on age and sexual activity: men under 35 years require ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover sexually transmitted organisms (gonorrhea and chlamydia), while men over 35 years need only levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days to target enteric bacteria. 1, 2
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Active)
Primary pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae are the causative organisms in this age group, with chlamydia accounting for two-thirds of cases previously labeled as "idiopathic" 1, 3, 4
First-line regimen: Ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 5
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 like E. coli in addition to sexually transmitted pathogens 1, 2, 3
Men Over 35 Years
Primary pathogens: Gram-negative enteric organisms, predominantly Escherichia coli, associated with urinary tract abnormalities, bladder outlet obstruction, or benign prostatic hyperplasia 1, 2, 6, 4
First-line regimen: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
Alternative: Ciprofloxacin 500 mg orally twice daily for 10 days, though rising fluoroquinolone resistance in E. coli is a growing concern 2, 6
Adjunctive Supportive Measures
Bed rest with scrotal elevation using a rolled towel or supportive underwear until fever and local inflammation subside 1, 2
Analgesics for pain control during the acute inflammatory phase 1, 2
Critical Management Points
Hospitalization Criteria
- Consider admission when severe pain suggests alternative diagnoses (testicular torsion, testicular infarction, or abscess), when patients are febrile, or when medication compliance is questionable 1
Diagnostic Workup Before Treatment
Urethral Gram stain: Look for >5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis and presumptively identify gonococcal infection 1
Nucleic acid amplification testing or culture: Obtain intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1, 2
First-void urine examination: Check for leukocytes if urethral Gram stain is negative; culture this specimen 1
Syphilis serology and HIV testing: Recommended for all patients with suspected sexually transmitted epididymitis 1, 2
Follow-Up Requirements
Reassess within 3 days: Failure to improve requires reevaluation of both diagnosis and treatment, as testicular torsion may have been missed initially 1, 2
Persistent swelling after treatment completion: Comprehensively evaluate for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2
Sexual Partner Management
Contact tracing: All sexual partners within the preceding 60 days must be evaluated and treated if epididymitis is caused by or suspected to be caused by N. gonorrhoeae or C. trachomatis 1, 2
Sexual abstinence: Patients must avoid all sexual intercourse until both they and their partners have completed therapy and are symptom-free 1, 2
Partner treatment rationale: Female partners of men with chlamydial epididymitis frequently have cervical chlamydial infection or pelvic inflammatory disease, even when asymptomatic 4
Common Pitfalls and Caveats
Antibiotic Selection Errors
Avoid ciprofloxacin monotherapy in men under 35: Ciprofloxacin does not adequately treat urogenital chlamydial infection, which is the predominant pathogen in this age group 7
Complete the full 10-day course: Stopping antibiotics early when symptoms improve can lead to treatment failure, chronic pain, and infertility 2, 3
Diagnostic Pitfalls
Testicular torsion mimics epididymitis: Sudden onset of severe pain, especially in adolescents or young men without evidence of infection or inflammation, requires emergency surgical consultation because testicular viability is time-dependent 1, 2
Urethritis is often asymptomatic: Sexually transmitted epididymitis is usually accompanied by urethritis, but patients may not report urinary symptoms 1
Special Populations
HIV-Infected Patients
Same treatment regimen: Uncomplicated epididymitis in HIV-positive patients requires the same antibiotics as HIV-negative patients 1, 2
Opportunistic pathogens: Fungi and mycobacteria are more likely causes in immunosuppressed patients and may require alternative diagnostic approaches and treatments 1, 2
Patients with Cephalosporin or Tetracycline Allergies
- Use fluoroquinolone monotherapy (levofloxacin or ofloxacin) for 10 days, though this may not adequately cover gonorrhea in younger patients 1