What are the recommended antibiotics and NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) for treating a patient with epididymitis?

Treatment of Epididymitis: Antibiotics and NSAIDs

Antibiotic Selection Based on Age and Risk Factors

The antibiotic regimen for epididymitis is determined primarily by patient age, with ceftriaxone 250 mg IM single dose plus doxycycline 100 mg orally twice daily for 10 days recommended for men under 35 years, and fluoroquinolone monotherapy (levofloxacin 500 mg once daily or ofloxacin 300 mg twice daily for 10 days) for men over 35 years. 1, 2

For Men Under 35 Years Old

• Administer ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover Chlamydia trachomatis and Neisseria gonorrhoeae, the predominant sexually transmitted pathogens in this age group 3, 1, 2, 4

• For men who practice insertive anal intercourse, modify the regimen to 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 provide enhanced coverage against enteric organisms 1, 2

For Men Over 35 Years Old

• Use fluoroquinolone monotherapy: either levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 3, 1, 2

• This age group typically has epididymitis caused by enteric organisms (particularly E. coli) secondary to bladder outlet obstruction and urinary reflux into the ejaculatory ducts, making fluoroquinolones the optimal choice 1, 5

Critical Caveat About Ciprofloxacin

• Avoid ciprofloxacin as first-line therapy in younger men despite its common use, as it provides suboptimal coverage for Chlamydia trachomatis, the most common pathogen in sexually active men under 35 6

NSAIDs and Adjunctive Therapy

All patients require analgesics (including NSAIDs) as adjunctive therapy until fever and local inflammation subside. 3, 1, 2

Mandatory Supportive Measures

• Prescribe analgesics (NSAIDs such as naproxen or ibuprofen) for pain control along with bed rest and scrotal elevation until fever and inflammation resolve 3, 1, 2, 7

• NSAIDs should be used at the lowest effective dose for the shortest duration necessary, with awareness of gastrointestinal and cardiovascular risks 7

• These adjunctive measures are not optional—they are recommended components of standard treatment to reduce morbidity and improve patient comfort 1, 2

Pre-Treatment Diagnostic Testing

Before initiating antibiotics, obtain the following tests to guide therapy and identify complications:

• Gram-stained smear of urethral exudate or intraurethral swab to diagnose urethritis (≥5 polymorphonuclear leukocytes per oil immersion field) 3, 1

• Nucleic acid amplification test (NAAT) or culture for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine 3, 1

• First-void urine examination for leukocytes with culture and Gram stain if urethral Gram stain is negative 3, 1

• Syphilis serology and HIV testing with counseling 3, 1

Treatment Duration and Follow-Up

• The minimum treatment duration is 10 days for all cases, regardless of clinical improvement 1, 2, 4

• Reevaluate within 72 hours of treatment initiation—failure to improve within 3 days mandates reassessment of both diagnosis and therapy 1, 2

• Persistent swelling and tenderness after completing antimicrobials requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, or tuberculous/fungal epididymitis 3, 1, 2

Sexual Partner Management

• Refer all sexual partners from the preceding 60 days for evaluation and treatment when epididymitis is caused by or suspected to be caused by N. gonorrhoeae or C. trachomatis 3, 1, 2

• Instruct patients to avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 3, 2

Special Populations

HIV-Infected or Immunocompromised Patients

• Use the same antibiotic regimens as HIV-negative patients for uncomplicated epididymitis 3, 1, 2

• Maintain higher suspicion for fungal and mycobacterial causes in immunosuppressed patients 3, 1, 2

Pediatric Patients

• In children under 14 years, epididymitis is most commonly caused by reflux of urine into the ejaculatory ducts rather than sexually transmitted organisms 5

• Consider withholding antibiotics in pediatric patients unless urinalysis or urine culture is positive, as only 10.8% of pediatric cases have bacterial etiology despite 81.7% receiving antibiotics 8

Common Pitfalls to Avoid

• Never delay empiric antibiotic therapy while waiting for culture results—treatment must begin immediately to prevent complications including infertility and chronic pain 3, 5

• Do not assume isolated orchitis—always treat as epididymo-orchitis since bacterial orchitis typically represents extension from epididymitis 1

• Always consider testicular torsion in the differential diagnosis, particularly in adolescents with sudden onset of severe pain—this is a surgical emergency requiring immediate consultation 3, 2

• Do not use ciprofloxacin as first-line therapy in men under 35 years despite its popularity, as it inadequately covers chlamydial infections 6