What is the recommended treatment for acute orchitis in an adult male, including empiric antimicrobial therapy, scrotal support, anti‑inflammatory measures, and appropriate diagnostic work‑up?

Treatment of Acute Orchitis in Adult Males

Initiate empiric antimicrobial therapy immediately based on age and risk factors: for sexually active men under 35 years, administer ceftriaxone 250 mg intramuscularly once plus doxycycline 100 mg orally twice daily for 10 days; for men 35 years or older or those with urologic risk factors, prescribe levofloxacin 500 mg orally once daily or ofloxacin 300 mg orally twice daily for 10 days. 1

Immediate Diagnostic Priorities

Before starting antibiotics, you must exclude testicular torsion—a surgical emergency where testicular viability declines after 4-6 hours. 1 If the diagnosis is uncertain, obtain immediate urological consultation rather than delaying for imaging. 1

Essential Laboratory Work-Up

• Urethral Gram stain: Look for ≥5 polymorphonuclear leukocytes per oil-immersion field, which confirms urethritis and guides empiric therapy. 1
• Nucleic acid amplification testing (NAAT): Obtain urethral swab or first-void urine for Neisseria gonorrhoeae and Chlamydia trachomatis. 1
• Urine analysis and culture: If the urethral Gram stain is negative, examine first-void urine for leukocytes and send for culture. 1

Age-Stratified Empiric Antibiotic Regimens

Men < 35 Years (Sexually Transmitted Etiology)

The predominant pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae. 1

• Ceftriaxone 250 mg intramuscularly as a single dose (covers gonorrhea)
• PLUS doxycycline 100 mg orally twice daily for 10 days (covers chlamydia) 1

Critical pitfall: Never use doxycycline alone in this population—it is insufficient for gonorrhea and will lead to treatment failure. 1

Men ≥ 35 Years or With Urologic Risk Factors

Enteric gram-negative organisms, especially Escherichia coli, predominate in patients with recent urinary instrumentation, anatomical urinary abnormalities, or diabetes. 1

• Levofloxacin 500 mg orally once daily for 10 days 1
• OR ofloxacin 300 mg orally twice daily for 10 days 1

Fluoroquinolones achieve excellent tissue penetration into the epididymis and testis. 1

Critical pitfall: Do not use doxycycline alone in men ≥35 years—it fails to cover enteric pathogens. 1

Allergy-Adjusted Options

For patients allergic to cephalosporins or tetracyclines, ofloxacin 300 mg orally twice daily for 10 days can cover both gonorrhea and chlamydia, though rising fluoroquinolone-resistant N. gonorrhoeae limits its desirability. 1

Supportive and Anti-Inflammatory Measures

• Bed rest until fever and local inflammation resolve 1
• Scrotal elevation and support to reduce pain and swelling 1
• Analgesics for pain control 1

These measures should continue until fever and inflammation subside. 1

Mandatory Reassessment and Surgical Indications

Re-evaluate at 72 hours: Lack of clinical improvement mandates reassessment of the diagnosis and therapy, and may require surgical exploration. 1

Hospitalization Criteria

Admit patients with: 1

• Severe scrotal or testicular pain suggesting alternative diagnoses (torsion, infarction, abscess)
• Fever ≥38°C
• Concerns about adherence to oral antimicrobial therapy

When to Consider Surgery

If no improvement occurs within 48-72 hours of antibiotic initiation, broaden the differential to include tumor, testicular infarction, fungal infection, or abscess formation requiring surgical drainage. 1, 2

Approximately 7% of severe genitourinary infections progress to urosepsis; monitor vital signs, lactate, complete blood count, and obtain blood cultures as needed. 1

Management of Sexual Partners

All sexual partners within 60 days preceding symptom onset should be evaluated and treated empirically. 1 Patients and partners must abstain from sexual activity until both have completed therapy and are asymptomatic. 1

Special Populations

HIV-infected or immunocompromised patients receive the same initial antibiotic regimens as immunocompetent individuals, but maintain heightened suspicion for atypical organisms (fungi, mycobacteria) if standard therapy fails. 1

Common Pitfalls to Avoid

• Never delay empiric therapy while awaiting culture results—start antibiotics promptly based on age and risk factors. 1
• Systemic antibiotics are required—topical agents alone are ineffective for epididymo-orchitis. 1
• Do not use monotherapy inappropriately: Doxycycline alone fails in men <35 years (no gonorrhea coverage) and in men ≥35 years (no enteric coverage). 1