How should acute epididymitis be treated in a 14-year-old male?

Treatment of Epididymitis in a 14-Year-Old Male

A 14-year-old male with acute epididymitis should receive ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days, targeting the sexually transmitted pathogens Chlamydia trachomatis and Neisseria gonorrhoeae that predominate in this age group. 1, 2, 3

Critical First Step: Exclude Testicular Torsion

• Testicular torsion is a surgical emergency that must be ruled out immediately in all adolescents presenting with acute scrotal pain, as testicular viability is compromised within 6–8 hours and this diagnosis is more common in adolescents than epididymitis. 1, 2
• Torsion typically presents with sudden onset of severe pain, whereas epididymitis develops gradually over hours to days with posterior scrotal tenderness. 1, 4
• If the diagnosis is uncertain or pain onset was abrupt, emergency surgical consultation and Doppler ultrasound are mandatory before initiating antibiotic therapy. 1, 2

Age-Specific Pathogen Considerations

• In sexually active males aged 14–35 years, C. trachomatis and N. gonorrhoeae are the predominant causative organisms, accounting for the majority of cases in this demographic. 1, 2, 3
• Even in adolescents who deny sexual activity, sexually transmitted infections remain the most common etiology and empiric coverage is warranted. 1, 5
• Enteric organisms (E. coli) are uncommon in this age group unless the patient practices insertive anal intercourse or has underlying urologic abnormalities. 1, 2

Recommended Antibiotic Regimen

• Ceftriaxone 250 mg intramuscularly as a single dose provides coverage for N. gonorrhoeae, including resistant strains. 1, 2, 3
• Doxycycline 100 mg orally twice daily for 10 days covers C. trachomatis and completes the dual-therapy regimen. 1, 2, 6, 3
• This combination is the CDC-recommended first-line treatment for epididymitis in males under 35 years. 1, 2

Dosing Considerations for Adolescents

• For children weighing less than 100 pounds (45 kg), doxycycline dosing is 2 mg/lb (2.2 mg/kg) divided into two doses on day 1, then 1 mg/lb daily (can be divided into two doses). 6
• For adolescents weighing 100 pounds or more, use the standard adult dose of 100 mg twice daily. 6
• A 14-year-old typically weighs enough to receive adult dosing, but verify weight before prescribing. 6

Alternative Regimen (Allergy to Cephalosporins or Tetracyclines)

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days can be used if the patient is allergic to ceftriaxone or doxycycline. 1, 2
• However, fluoroquinolones are generally avoided in adolescents due to concerns about cartilage toxicity, so allergy testing or desensitization should be considered first. 1

Diagnostic Evaluation (Obtain Before or Concurrent with Treatment)

• Urethral Gram stain (≥5 polymorphonuclear leukocytes per oil-immersion field indicates urethritis) should be performed if urethral discharge is present. 1, 4
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis from a urethral swab or first-void urine specimen is essential. 1, 4, 2
• First-void urine examination for leukocytes (pyuria) if urethral Gram stain is negative or unavailable. 1, 4
• Syphilis serology and HIV counseling/testing should be offered to all patients with suspected sexually transmitted epididymitis. 1, 2
• Do not delay antibiotic therapy while awaiting test results—treatment is empiric and should begin immediately after specimens are collected. 1

Adjunctive Supportive Care

• Bed rest, scrotal elevation (using a scrotal supporter), and analgesics (NSAIDs or acetaminophen) until fever and local inflammation resolve. 1, 4, 2
• Anti-inflammatory medications help control pain and swelling. 4
• Advise the patient to avoid strenuous activity until symptoms improve. 4

Mandatory Follow-Up

• Reassess the patient within 3 days to confirm clinical improvement (reduction in pain, swelling, and tenderness). 1, 4, 2
• If no improvement occurs within 72 hours, re-evaluate both the diagnosis and the antibiotic regimen—consider alternative diagnoses such as abscess, tumor, or testicular torsion. 1, 4, 2
• Persistent symptoms after completing the 10-day antibiotic course warrant comprehensive evaluation for complications including epididymal abscess, testicular infarction, tuberculosis, fungal infection, or malignancy. 1, 2

Management of Sexual Partners

• All sexual partners from the preceding 60 days must be referred for evaluation and empiric treatment for N. gonorrhoeae and C. trachomatis, regardless of the index patient's test results. 1, 2
• The patient must abstain from sexual intercourse until both he and all partners have completed therapy and are symptom-free. 1, 2
• Expedited partner therapy (providing prescriptions for partners without examination) may be considered where legally permissible. 1

Common Pitfalls to Avoid

• Failure to exclude testicular torsion can result in testicular loss—maintain high suspicion in any adolescent with acute scrotal pain. 1, 2
• Monotherapy with a fluoroquinolone alone (e.g., ciprofloxacin) is inadequate in this age group because it does not reliably cover C. trachomatis. 1
• Relying solely on urinalysis misses most STI-related cases, as these infections originate from urethral pathogens rather than urinary bacteria—urethral swab testing is essential. 4
• Not treating sexual partners leads to reinfection and perpetuates transmission. 1, 2
• Prescribing trimethoprim-sulfamethoxazole (Bactrim) is inappropriate, as it does not cover the relevant pathogens in this age group. 4

Special Considerations in Adolescents

• Epididymitis in prepubertal boys (under 14 years) is typically non-infectious and may be post-infectious or inflammatory, often following viral illness or associated with conditions like Henoch-Schönlein purpura. 7
• However, a 14-year-old is considered sexually active age for treatment purposes, and the sexually transmitted etiology must be assumed unless proven otherwise. 1, 3
• Confidentiality and non-judgmental counseling about sexual health are essential when treating adolescents. 1