What is the recommended management for epididymitis in an 80‑year‑old man?

Management of Epididymitis in an 80-Year-Old Man

In an 80-year-old man with epididymitis, treat empirically with levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) to cover enteric Gram-negative organisms, particularly Escherichia coli, which are the predominant pathogens in men over 35 years of age. 1, 2, 3

Age-Based Pathogen Considerations

• Men ≥35 years develop epididymitis primarily from enteric Gram-negative bacteria, especially E. coli, rather than sexually transmitted organisms. 4, 1, 5
• These infections typically arise from urinary reflux into the ejaculatory ducts, often associated with bladder outlet obstruction, benign prostatic hyperplasia, or recent urinary tract instrumentation. 4, 1, 5
• A recent European study using advanced molecular diagnostics found E. coli in 56% of cases, confirming enteric organisms as the dominant etiology. 6
• Sexually transmitted infections (Chlamydia trachomatis, Neisseria gonorrhoeae) account for only 14% of all epididymitis cases and are not restricted to younger men, though they remain far less common in the elderly population. 6

Recommended Antibiotic Regimen

Fluoroquinolone monotherapy is the first-line treatment for men over 35 years:

• Levofloxacin 500 mg orally once daily for 10 days 1, 2, 3, 5
• Alternative: Ofloxacin 300 mg orally twice daily for 10 days 4, 1, 2

The 2015 European Urology study demonstrated that cultured bacteria in antibiotic-naive patients showed >85% susceptibility to fluoroquinolones, validating this empiric choice. 6

Do not use the ceftriaxone plus doxycycline regimen in this age group—that combination targets sexually transmitted pathogens (N. gonorrhoeae and C. trachomatis) and is indicated only for sexually active men under 35 years. 4, 1, 2

Essential Diagnostic Evaluation

Before initiating antibiotics (but do not delay treatment):

• Urinalysis with microscopy for pyuria (≥5 WBCs per high-power field) 4, 1
• Urine culture and Gram stain for Gram-negative bacteria 4, 1, 3
• Consider urethral swab only if urethritis symptoms are present (dysuria, discharge), though this is uncommon in elderly men 4, 1

In men over 35 years, pyuria is typically present because epididymitis is caused by urinary tract pathogens; urine studies are therefore the highest-yield diagnostic tests. 1

Critical Differential Diagnosis: Exclude Testicular Torsion

Testicular torsion is a surgical emergency that must be ruled out immediately, even though it is far more common in adolescents. 4, 1, 2

Key distinguishing features:

• Torsion: sudden, severe pain with rapid onset 1, 3
• Epididymitis: gradual onset over hours to days, posterior scrotal pain 3, 5
• Positive Prehn sign (pain relief with scrotal elevation) suggests epididymitis 3
• If diagnosis is uncertain or pain onset is abrupt, obtain emergency Doppler ultrasound or immediate urology consultation—testicular viability is lost within 6–8 hours. 1, 3

Adjunctive Supportive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 4, 1, 2
• Scrotal support reduces edema and improves comfort 3
• NSAIDs can be used for pain control 3

Follow-Up and Treatment Failure

• Reassess the patient within 3 days if no clinical improvement occurs—this requires re-evaluation of both diagnosis and antibiotic choice. 4, 1, 2, 3
• If symptoms persist after completing the 10-day antibiotic course, perform comprehensive evaluation for alternative diagnoses: testicular tumor, epididymal abscess, testicular infarction, testicular cancer, tuberculous epididymitis, or fungal epididymitis. 4, 1, 2
• Consider Doppler ultrasound if diagnosis remains uncertain or if no response to appropriate therapy occurs. 3

Special Considerations in Elderly Men

• Investigate for underlying urologic abnormalities—bladder outlet obstruction from benign prostatic hyperplasia is common in 80-year-old men and predisposes to recurrent epididymitis. 4, 5
• Obtain history of recent urinary catheterization, cystoscopy, or prostate biopsy, as instrumentation increases risk of enteric organism infection. 4
• In immunosuppressed patients (e.g., diabetes, chronic steroids, malignancy), fungi and mycobacteria are more likely pathogens—if standard therapy fails, consider these atypical organisms. 1, 2

Common Pitfalls to Avoid

• Do not use ciprofloxacin as first-line therapy—while it covers enteric organisms, it has inadequate activity against C. trachomatis if STI is present; levofloxacin or ofloxacin are preferred fluoroquinolones. 1
• Do not use nitrofurantoin or fosfomycin—these agents have inadequate tissue penetration into the epididymis. 3
• Do not assume all cases require antibiotics without confirming infection—obtain urinalysis to document pyuria and guide therapy. 1
• Do not delay urology referral if torsion cannot be excluded—when in doubt, surgical exploration is warranted. 1, 3

Hospitalization Criteria

Consider admission for:

• Severe pain suggesting abscess, infarction, or torsion 1, 2
• Fever with systemic toxicity 1, 2
• Inability to tolerate oral medications 2
• Concern for medication non-compliance 2
• Signs of necrotizing infection (crepitus, rapidly spreading erythema) 3