What is the recommended treatment for epididymitis in men under 35 versus men 35 or older, including empiric antibiotics, supportive care, and follow‑up?

Treatment of Epididymitis

For men under 35 years, give ceftriaxone 250 mg IM once plus doxycycline 100 mg orally twice daily for 10 days; for men 35 years or older, give levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice daily for 10 days. 1

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Active)

Primary pathogens: Chlamydia trachomatis and Neisseria gonorrhoeae are the predominant organisms in this age group 1, 2

First-line regimen:

• Ceftriaxone 250 mg intramuscularly as a single dose 1
• PLUS doxycycline 100 mg orally twice daily for 10 days 1
• This dual therapy specifically targets both N. gonorrhoeae and C. trachomatis 1

Special consideration for men who have sex with men (insertive anal intercourse):

• Use ceftriaxone 250 mg IM once PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) 1
• This modification covers enteric organisms such as E. coli that can be sexually transmitted during anal intercourse 2

Allergy alternative:

• If allergic to cephalosporins or tetracyclines, use levofloxacin 500 mg orally once daily for 10 days or ofloxacin 300 mg orally twice daily for 10 days 1

Men 35 Years or Older

Primary pathogens: Enteric gram-negative bacteria, especially Escherichia coli, predominate in this age group 1, 2

First-line regimen:

• Levofloxacin 500 mg orally once daily for 10 days 1
• OR ofloxacin 300 mg orally twice daily for 10 days 1
• Fluoroquinolone monotherapy is sufficient because sexually transmitted infections are less common in this population 1

Underlying risk factors to investigate:

• Bladder outlet obstruction from benign prostatic hyperplasia 1
• Recent urinary tract instrumentation (catheterization, cystoscopy, prostate biopsy) 1
• These conditions predispose to urinary reflux into the ejaculatory ducts 1

Critical Diagnostic Steps Before Treatment

Do not delay antibiotics while awaiting results, but obtain:

• Urethral Gram stain: ≥5 polymorphonuclear leukocytes per oil-immersion field indicates urethritis 1
• Nucleic acid amplification testing (NAAT) or culture from intra-urethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
• First-void urine examination for leukocytes if urethral Gram stain is negative 1
• Urine culture and Gram stain (especially in men ≥35 years) to identify gram-negative organisms 1
• Syphilis serology and HIV testing should be offered to all patients 1

Essential Supportive Care

All patients require adjunctive measures:

• Bed rest until fever and local inflammation subside 1
• Scrotal elevation (reduces venous congestion and pain) 1
• Analgesics for pain control 1

Critical Pitfall: Excluding Testicular Torsion

Testicular torsion is a surgical emergency that must be ruled out immediately, especially:

• In adolescents 1
• When pain onset is sudden and severe 1
• When there is no clinical evidence of inflammation or infection 1
• Emergency surgical consultation is required when torsion is suspected, as testicular viability is compromised after 4-6 hours 1

Follow-Up Protocol

Reassess within 3 days if no clinical improvement occurs 1

If symptoms persist after completing the full antibiotic course, perform comprehensive evaluation for:

• Testicular tumor 1
• Epididymal abscess 1
• Testicular infarction 1
• Testicular cancer 1
• Tuberculous epididymitis 1
• Fungal epididymitis (especially in immunosuppressed patients) 1, 2

Management of Sexual Partners

For suspected or confirmed STI-related epididymitis:

• Refer all sexual partners from the preceding 60 days for evaluation and treatment 1
• Patient must abstain from sexual intercourse until both patient and all partners complete therapy and are symptom-free 1

Common Prescribing Errors to Avoid

Do NOT use ciprofloxacin as first-line therapy in men <35 years because it does not adequately cover C. trachomatis 1

Do NOT use the ceftriaxone + doxycycline combination in men ≥35 years unless there is clear evidence of sexually transmitted infection, as this regimen does not cover enteric gram-negative organisms 1

Special Populations

HIV-positive patients:

• Receive the same treatment regimens as HIV-negative patients for uncomplicated epididymitis 1
• However, fungi and mycobacteria are more likely causative agents in immunosuppressed patients 1, 2

Consider hospitalization for:

• Severe pain suggesting alternative diagnoses (torsion, abscess, infarction) 1
• Febrile patients 1
• Uncertain outpatient compliance 1