What is the recommended management of acute epididymitis, including empiric antibiotic therapy for men under 35 years old versus men 35 years and older?

Management of Acute Epididymitis

Empiric Antibiotic Therapy Based on Age and Risk Factors

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover gonorrhea and chlamydia. 1, 2, 3, 4

Age-Based Treatment Algorithm

Men < 35 years (sexually transmitted etiology):

• Primary regimen: Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg PO twice daily for 10 days 1, 2, 3
• This covers Chlamydia trachomatis and Neisseria gonorrhoeae, 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 PO once daily for 10 days OR ofloxacin 300 mg PO twice daily for 10 days to cover enteric organisms 4

Men ≥ 35 years (enteric organism etiology):

• Primary regimen: Levofloxacin 500 mg PO once daily for 10 days OR ofloxacin 300 mg PO twice daily for 10 days 1, 2, 4
• Enteric Gram-negative organisms (especially E. coli) predominate in this age group, typically associated with bladder outlet obstruction or urinary tract abnormalities 1, 4, 5
• Fluoroquinolone monotherapy is sufficient as sexually transmitted infections are less common 1, 4

Alternative regimens (allergies to cephalosporins/tetracyclines):

• Ofloxacin 300 mg PO twice daily for 10 days OR levofloxacin 500 mg PO once daily for 10 days 1

Diagnostic Evaluation Before Treatment

Obtain these tests before initiating empiric therapy, but do not delay treatment while awaiting results 1, 2:

• Urethral Gram stain: Look for ≥5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 1, 2
• Nucleic acid amplification test (NAAT) or culture: From 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; obtain culture and Gram stain of uncentrifuged urine 1, 2
• Syphilis serology and HIV testing: Offer counseling and testing to all patients 1, 2

Adjunctive Supportive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1, 2
• These measures are recommended as adjuncts to antimicrobial therapy 1

Follow-Up and Treatment Failure

• Reassess within 3 days if no clinical improvement occurs 1, 2
• Reevaluate both the diagnosis and antibiotic choice if symptoms persist 1
• Persistent swelling/tenderness after completing antibiotics requires comprehensive evaluation for alternative diagnoses including tumor, abscess, testicular infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2

Critical Pitfall: Ruling Out Testicular Torsion

Testicular torsion is a surgical emergency that must be excluded in all cases, especially in adolescents and when pain onset is sudden and severe. 1, 2, 4

• Torsion occurs more frequently in patients without evidence of inflammation or infection 1
• Immediate specialist consultation is required if diagnosis is uncertain, as testicular viability may be compromised 2
• Emergency testing for torsion is indicated when onset is sudden, pain is severe, or initial examination does not confirm urethritis or urinary tract infection 1, 2

Management of Sexual Partners

• Refer all sexual partners from the preceding 60 days for evaluation and treatment if epididymitis is confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis 1, 2
• Instruct patients to abstain from sexual intercourse until both patient and partner(s) complete therapy and are symptom-free 1, 2
• Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease and require treatment 5

Special Populations

HIV-infected patients:

• Use the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 1, 2
• Be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1, 2

Hospitalization considerations:

• Consider admission when severe pain suggests alternative diagnoses (torsion, abscess, infarction), when patients are febrile, or when compliance with outpatient therapy is questionable 1

Common Prescribing Errors to Avoid

Ciprofloxacin is NOT optimal for chlamydial infection and should not be used as first-line therapy in men under 35 years, despite being commonly prescribed in practice 6. The fluoroquinolones recommended in guidelines are specifically levofloxacin or ofloxacin, not ciprofloxacin 1, 4.