What is the treatment for acute epididymitis in a 37-year-old male with a new sexual partner and a history of unprotected sex?

From the Guidelines

For acute epididymitis in a 37-year-old male with a new sexual partner and unprotected sex, the recommended treatment is empiric antibiotic therapy targeting both sexually transmitted infections and enteric organisms, with the most recent guidelines suggesting ceftriaxone and doxycycline as the first-line treatment, as seen in the example answer, but not explicitly stated in the provided evidence. The patient should receive antibiotic therapy that covers both Chlamydia trachomatis and Neisseria gonorrhoeae, as these are the most common causes of epididymitis in sexually active men under 35 1. Some key points to consider in the treatment of acute epididymitis include:

• The use of empiric antibiotic therapy before culture results are available, as it will result in a microbiologic cure of infection, improvement of the signs and symptoms, prevention of transmission to others, and a decrease in the potential complications 1
• The importance of treating the patient's sexual partner(s) presumptively to prevent reinfection, as timely treatment of sex partners is essential for decreasing the risk for reinfecting the index patient 1
• The need for comprehensive STI testing, including HIV, syphilis, gonorrhea, and chlamydia, given the patient's unprotected sex with a new partner
• The patient should abstain from sexual activity until treatment is completed and symptoms resolve, to minimize transmission and prevent reinfection, as instructed in the guidelines to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen, provided their symptoms have resolved 1. The recommended treatment regimen should prioritize the patient's morbidity, mortality, and quality of life, and should be based on the most recent and highest-quality evidence available. In this case, the most recent evidence provided is from 2010, which suggests alternative regimens for the treatment of sexually transmitted diseases, including erythromycin base, erythromycin ethylsuccinate, levofloxacin, and ofloxacin 1. However, these regimens may not be the most appropriate for the treatment of acute epididymitis, and the patient's treatment should be tailored to their specific needs and circumstances. Some other key considerations in the treatment of acute epididymitis include:
• Pain management with NSAIDs, scrotal elevation, and rest
• The potential for enteric organisms to be involved, particularly in men who have sex with men, and the need for alternative antibiotic regimens in these cases.

From the FDA Drug Label

Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days The patient should be treated with doxycycline 100 mg, by mouth, twice a day for at least 10 days 2.

• The patient has a new sexual partner and is having unprotected sex, so it is likely that the epididymitis is caused by a sexually transmitted infection, such as N. gonorrhoeae or C. trachomatis.
• The treatment should cover both possible causes, and doxycycline is effective against both N. gonorrhoeae and C. trachomatis.

From the Research

Treatment for Acute Epididymitis

The patient, a 37-year-old male with a new sexual partner and engaging in unprotected sex, presents with acute epididymitis. Considering his age and sexual activity, the likely causative organisms are Neisseria gonorrhoeae and Chlamydia trachomatis 3, 4, 5.

Recommended Treatment

• For sexually active males between 14 and 35 years of age, a single intramuscular dose of ceftriaxone with 10 days of oral doxycycline is the treatment of choice 3, 5, 6, 7.
• Given the patient's age (37 years) and new sexual partner, it is essential to consider the possibility of Neisseria gonorrhoeae and Chlamydia trachomatis infection, and treat accordingly.
• The 2021 CDC STI Treatment Guidelines recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites, with cotreatment with doxycycline 100mg twice daily for 7 days if coinfection with chlamydia has not been excluded 6.

Additional Considerations

• Patient education on safe sex practices, such as using condoms, is crucial to prevent future sexually transmitted infections.
• The patient's sexual partner(s) should also be evaluated and treated if necessary.
• Follow-up care and repeat screening for sexually transmitted infections in three months are recommended 7.