Acute Epididymitis: Initial Evaluation and Empiric Antibiotic Therapy
Immediate Diagnostic Priority: Exclude Testicular Torsion
Before initiating any workup, testicular torsion must be excluded—it is a surgical emergency that causes testicular loss within 6–8 hours if untreated. 1, 2
- Torsion presents with sudden, severe pain versus the gradual onset over hours to days typical of epididymitis 2
- Torsion occurs more frequently in adolescents and patients without signs of inflammation or infection 1
- Emergency urologic consultation is mandatory when pain onset is abrupt, severity is extreme, or initial examination does not confirm urethritis or urinary-tract infection 2
- Doppler ultrasound may be obtained if diagnosis is uncertain, but do not delay surgical consultation 2
Essential Diagnostic Evaluation (Perform Before Antibiotics, But Do Not Delay Treatment)
Clinical Examination
- Unilateral testicular pain and tenderness with palpable epididymal swelling beginning at the lower pole and progressing upward 1, 2
- Positive Prehn sign (pain relief with scrotal elevation) helps differentiate from torsion 2
- Reactive hydrocele may be present 2
Laboratory Testing
For all patients:
- Urethral Gram stain of urethral exudate or intraurethral swab: ≥5 polymorphonuclear leukocytes per oil-immersion field indicates urethritis 1, 2
- Nucleic acid amplification test (NAAT) from intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1, 2
- First-void urine microscopy (uncentrifuged) for leukocytes if urethral Gram stain is negative 1, 2
- Urine culture and Gram stain to identify enteric organisms 1, 2
- Syphilis serology and HIV testing 1, 2
Age-Based Empiric Antibiotic Therapy
Men < 35 Years (Sexually Active)
Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2, 3
- This regimen targets N. gonorrhoeae and C. trachomatis, the predominant pathogens in this age group 1, 2, 3
- Sexually transmitted epididymitis usually accompanies urethritis, which is often asymptomatic 1
- Do not use fluoroquinolone monotherapy in this age group—it fails to adequately cover chlamydia 2
Special consideration for men who practice insertive anal intercourse:
- Use 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) 2, 3
- Enteric organisms (especially E. coli) are more likely in this population 1, 3
Men ≥ 35 Years
Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 2, 3
- Enteric Gram-negative organisms, particularly E. coli, predominate in this age group 1, 2, 3
- These infections result from urinary reflux into ejaculatory ducts, often associated with bladder outlet obstruction, benign prostatic hyperplasia, or recent urinary instrumentation 1, 2
- Do not use the ceftriaxone + doxycycline regimen in men ≥35 years—it targets sexually transmitted pathogens and is inappropriate for enteric organisms 2
Patients with Cephalosporin or Tetracycline Allergy
- Use ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2
Adjunctive Supportive Care
- Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside 1, 2
- Scrotal support reduces edema 4
- Anti-inflammatory medications control pain 4
Mandatory Follow-Up and Red Flags
3-Day Reassessment
If no clinical improvement occurs within 3 days, reevaluate both the diagnosis and the antibiotic regimen. 1, 2, 4
- Expect reduction in pain, swelling, and tenderness as markers of therapeutic response 2
- Lack of improvement warrants consideration of alternative diagnoses or antibiotic resistance 2, 4
Persistent Symptoms After Completing Antibiotics
Comprehensive evaluation is required for swelling or tenderness that persists after the 10-day course. 1, 2
- Differential diagnosis includes:
- Doppler ultrasound should be obtained 4
- Urine culture with antibiogram guides therapeutic adjustments 4
Management of Sexual Partners (For Sexually Transmitted Epididymitis)
- Refer all sexual partners from the preceding 60 days for evaluation and empiric treatment covering both N. gonorrhoeae and C. trachomatis 1, 2
- Patients must abstain from sexual intercourse until they and all partners have completed therapy and are symptom-free 1, 2
- Female partners of men with C. trachomatis epididymitis frequently have cervical infection or pelvic inflammatory disease 5, 6
Hospitalization Criteria
Consider admission for: 1
- Severe pain suggesting alternative diagnoses (torsion, abscess, infarction)
- Fever
- Concern for noncompliance with outpatient antimicrobial therapy
Special Populations
HIV-Positive Patients
- Treat uncomplicated epididymitis with the same regimens as HIV-negative patients 2
- Maintain higher suspicion for fungal and mycobacterial causes in immunosuppressed patients 1, 2
Men with Recent Urinary Instrumentation or Anatomical Abnormalities
- These patients are at higher risk for enteric organisms 1
- Investigate underlying urologic abnormalities, particularly bladder outlet obstruction from benign prostatic hyperplasia 2
Common Pitfalls to Avoid
- Failure to exclude testicular torsion can result in testicular loss—maintain high suspicion with sudden onset or severe pain 1, 2
- Using fluoroquinolone monotherapy in men <35 years fails to cover both gonorrhea and chlamydia adequately 2
- Relying solely on urinalysis in younger men misses the majority of STI-related cases, which originate from urethral pathogens rather than urinary bacteria 2
- Inadequate follow-up—failure to reassess at 3 days delays recognition of treatment failure or alternative diagnoses 1, 2, 4
- Not obtaining cultures before antibiotics—urine culture with susceptibility testing is crucial when the initial regimen is ineffective 2