Can Levaquin Cause Scrotal Tenderness?
Levaquin (levofloxacin) does not directly cause scrotal tenderness as a drug side effect; however, scrotal tenderness is a symptom of epididymoorchitis, which levofloxacin is specifically used to treat. If you are experiencing scrotal tenderness while taking levofloxacin, this represents the underlying infection, not a medication adverse effect.
Understanding the Clinical Context
Scrotal tenderness is a hallmark symptom of epididymoorchitis—inflammation of the epididymis and/or testis—not a known adverse reaction to fluoroquinolone antibiotics. 1
When Levofloxacin Is Indicated for Scrotal Tenderness
Levofloxacin 500 mg once daily for 10 days is the first-line treatment for epididymoorchitis in men ≥35 years or those with urologic risk factors (recent urinary instrumentation, anatomic abnormalities, diabetes), where enteric gram-negative organisms like E. coli predominate. 1, 2, 3
The drug achieves excellent tissue penetration into the epididymis and testis, with concentrations exceeding the MIC90 for typical uropathogens. 4, 5
Age-Based Treatment Algorithm
Men <35 years (sexually transmitted etiology): Ceftriaxone 250 mg IM single dose plus doxycycline 100 mg orally twice daily for 10 days to cover N. gonorrhoeae and C. trachomatis. 1, 3
Men ≥35 years (enteric organism etiology): Levofloxacin 500 mg once daily or ofloxacin 300 mg twice daily for 10 days to cover gram-negative bacteria. 1, 2, 3
Men who practice insertive anal intercourse: Levofloxacin 500 mg once daily plus doxycycline 100 mg twice daily for 10 days to cover both sexually transmitted and enteric pathogens simultaneously. 1
Critical Diagnostic Steps Before Treatment
Before attributing scrotal tenderness to any cause, testicular torsion must be urgently excluded, especially in adolescents or when inflammatory signs are absent, as testicular viability declines after 4-6 hours. 1
Essential Workup
Urethral Gram stain: ≥5 polymorphonuclear leukocytes per oil-immersion field confirms urethritis. 1, 6
Nucleic acid amplification testing (NAAT): Perform on urethral swab or first-void urine for N. gonorrhoeae and C. trachomatis. 1, 6
Urine culture: First-void urine should be examined for leukocytes and cultured for gram-negative organisms, particularly in men ≥35 years. 1, 6
When to Hospitalize
Admission is warranted if: 1, 2
- Severe scrotal or testicular pain suggesting torsion, infarction, or abscess
- Fever ≥38°C requiring close monitoring
- Concerns about medication adherence
Monitoring and Red Flags
Re-evaluate at 72 hours; lack of clinical improvement mandates reassessment of diagnosis and consideration of surgical exploration. 1 Approximately 7% of severe genitourinary infections progress to urosepsis—monitor vital signs, lactate, and obtain blood cultures as needed. 1
Common Pitfalls to Avoid
Do not use doxycycline alone in men ≥35 years—it fails to cover enteric pathogens and leads to treatment failure. 1, 2
Do not delay empiric therapy while awaiting culture results; treatment should be initiated immediately based on age and risk factors. 2
Scrotal tenderness persisting beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome. 7
Supportive Care
Provide bed rest, scrotal elevation, and analgesics until fever and local inflammation resolve. 1, 2 Patients must abstain from sexual activity until therapy is completed and symptoms resolve. 1, 6
Partner Management
All sexual partners within 60 days preceding symptom onset should be evaluated and treated empirically for sexually transmitted infections. 1, 6