Treatment of Epididymorchitis
For men under 35 years with epididymorchitis, administer ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover sexually transmitted pathogens. 1, 2, 3
Age-Based Treatment Algorithm
Men Under 35 Years (Sexually Transmitted Etiology)
Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days is the recommended first-line regimen, targeting Chlamydia trachomatis and Neisseria gonorrhoeae which are the predominant pathogens in this age group. 1, 2, 4, 5
For men who practice insertive anal intercourse, use ceftriaxone 250 mg IM single dose PLUS a fluoroquinolone (ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days) to cover enteric organisms like E. coli that are transmitted during anal intercourse. 1, 2, 4
The doxycycline component must be continued for the full 10 days as C. trachomatis epididymitis accounts for two-thirds of cases in young men and is associated with oligospermia if inadequately treated. 5
Men Over 35 Years (Enteric Organism Etiology)
Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days as monotherapy is sufficient, since enteric organisms (particularly E. coli) associated with urinary tract infections are the predominant cause in this age group. 1, 2, 4
These patients often have underlying bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture disease causing urinary reflux into the ejaculatory ducts. 6, 4, 7
Critical caveat: Rising fluoroquinolone resistance in E. coli isolates means that if the patient fails to improve within 3 days, obtain urine culture with antimicrobial susceptibility testing and adjust therapy accordingly. 6
Essential Adjunctive Measures
Bed rest, scrotal elevation, and analgesics should be prescribed until fever and local inflammation subside, as these measures reduce pain and swelling while antibiotics address the infection. 1, 2
Adequate fluid intake with doxycycline administration is mandatory to reduce the risk of esophageal irritation and ulceration. 3
Mandatory Follow-Up Protocol
Reassess within 3 days of initiating treatment; failure to show clinical improvement (reduction in pain, swelling, and tenderness) requires immediate reevaluation of both diagnosis and treatment regimen. 1, 8, 2
If swelling and tenderness persist after completing the full antimicrobial course, perform comprehensive evaluation for alternative diagnoses including testicular tumor, abscess, infarction, testicular cancer, tuberculosis, and fungal epididymitis. 1, 8, 2
Reculture for N. gonorrhoeae and C. trachomatis with antimicrobial susceptibility testing if initial therapy fails, as treatment failure may indicate resistant organisms. 8
Critical Management of Sexual Partners
All sexual partners from the 60 days preceding symptom onset must be evaluated and treated empirically with regimens effective against both C. trachomatis and N. gonorrhoeae, regardless of the apparent etiology or pathogens isolated from the infected patient. 9, 8, 2
Patients must avoid sexual intercourse until both they and all partners complete treatment and are completely asymptomatic. 1, 8, 2
Reinfection from untreated partners is the most common cause of persistent symptoms, not treatment failure. 8
Special Populations
HIV-Infected Patients
HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients. 1, 2
However, fungi and mycobacteria are more likely causative organisms in immunosuppressed patients, so obtain fungal cultures and mycobacterial studies if standard therapy fails. 1, 8
Pregnant Partners
- Female sexual partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease and require evaluation and treatment. 5
Critical Pitfalls to Avoid
Never miss testicular torsion: This surgical emergency must be ruled out in all cases of acute testicular pain, especially in adolescents and when pain onset is sudden and severe. Immediate specialist consultation is required as testicular viability may be compromised within 4-6 hours. 1, 8, 2, 7
Do not continue empiric antibiotics beyond 3 days without clinical improvement; reevaluation is mandatory to avoid missing alternative diagnoses or resistant organisms. 8
Do not assume all persistent symptoms represent treatment failure; reinfection from untreated partners is far more common and must be addressed through partner management. 8
In men over 35 years with urinary tract infection-associated epididymitis, examine for palpable bladder and perform digital rectal exam to identify underlying bladder outlet obstruction requiring urological intervention. 7