What is the appropriate management for a young to middle-aged man with a history of sexually transmitted infections (STIs) or urinary tract infections (UTIs) presenting with testicular pain?

Management of Testicular Pain in Young to Middle-Aged Men with STI/UTI History

For men under 35 with testicular pain and STI history, immediately initiate empiric treatment with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days to cover gonorrhea and chlamydia, while for men over 35 with UTI history, use levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days to target enteric organisms. 1, 2

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

• First-line empiric therapy: Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This regimen targets Chlamydia trachomatis and Neisseria gonorrhoeae, the most common pathogens in sexually active younger men 1, 3
• Sexually transmitted epididymitis typically accompanies urethritis, which is often asymptomatic 1

Men Over 35 Years (Enteric Organism Etiology)

• First-line empiric therapy: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2
• These fluoroquinolones target Gram-negative enteric organisms, particularly E. coli, which predominate in older men 1, 2
• Nonsexually transmitted epididymitis occurs more frequently in men over 35, especially those with recent urinary tract instrumentation, surgery, or anatomical abnormalities 1

Critical Diagnostic Considerations Before Treatment

Rule Out Testicular Torsion FIRST

• Testicular torsion is a surgical emergency requiring immediate specialist consultation if pain onset is sudden and severe, as testicular viability is compromised within 4-6 hours 2, 4
• Torsion occurs more frequently in adolescents and men without evidence of inflammation or infection 1
• Emergency testing for torsion is indicated when initial examination does not support urethritis or urinary tract infection 1

Essential Diagnostic Testing

• Gram-stained smear of urethral exudate or intraurethral swab for urethritis diagnosis (>5 polymorphonuclear leukocytes per oil immersion field) and presumptive gonococcal infection 1
• Nucleic acid amplification test (NAAT) on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1, 2
• First-void urine examination for leukocytes if urethral Gram stain is negative, with culture and Gram stain of this specimen 1
• Syphilis serology and HIV counseling/testing as part of comprehensive STI evaluation 1, 2

Adjunctive Supportive Care

• Bed rest with scrotal elevation (using rolled towel or supportive underwear) until fever and local inflammation subside 1, 2, 4
• Analgesics for pain control during the acute phase 1, 2

Hospitalization Criteria

Consider hospitalization when: 1

• Severe pain suggests alternative diagnoses (torsion, testicular infarction, abscess)
• Patient is febrile
• Concern for noncompliance with antimicrobial regimen

Mandatory Follow-Up and Red Flags

3-Day Reassessment Rule

• Failure to improve within 3 days of initiating treatment requires reevaluation of both diagnosis and therapy 1, 2, 4
• This is a critical checkpoint that cannot be missed, as persistent symptoms may indicate incorrect diagnosis or treatment failure 2

Post-Treatment Evaluation

• Swelling and tenderness persisting after antimicrobial therapy completion requires comprehensive evaluation for tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1

Sexual Partner Management

• All sexual partners from the past 60 days must be evaluated and treated if epididymitis is confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis 1, 2
• Patients must abstain from sexual intercourse until both they and their partners complete therapy and are symptom-free 1, 2

Special Populations

HIV-Infected Patients

• HIV-positive patients with uncomplicated epididymitis receive the same treatment regimen as HIV-negative patients 1, 2, 4
• However, fungi and mycobacteria are more likely causes in immunosuppressed patients than in immunocompetent individuals 1, 2

Patients with Insertive Anal Intercourse

• Men who are insertive partners during anal intercourse may develop epididymitis from sexually transmitted enteric organisms like E. coli 1
• These patients may require fluoroquinolone coverage even if under 35 years old 1

Common Pitfalls to Avoid

• Never assume improvement means cure—the full 10-day antibiotic course is mandatory to prevent chronic complications like infertility or chronic pain 1, 2
• Don't miss testicular torsion—when in doubt, consult urology immediately rather than initiating antibiotics 1, 4
• Don't overlook partner treatment—untreated partners perpetuate reinfection cycles 1, 2
• Don't ignore the age cutoff—using STI-directed therapy in older men or enteric-directed therapy in younger men leads to treatment failure 1, 2

Nuances in Recent Evidence

While older CDC guidelines from 1998-2002 established the foundational treatment approach 1, more recent evidence suggests consideration of higher-dose ceftriaxone (1g IM) for gonorrhea coverage due to emerging resistance patterns 5. However, the 250 mg dose remains the FDA-approved standard 6. The core age-based algorithmic approach remains consistent across all guideline iterations 1, 2, 3.