Initial Treatment for Epididymitis

Etiology and Diagnosis

In sexually active men under 35 years of age, epididymitis is most commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae, according to the Centers for Disease Control and Prevention (CDC) 3
Sexually transmitted Escherichia coli is a cause of epididymitis, particularly in men who are insertive partners during anal intercourse, as reported by the CDC 2
A Gram-stained smear of urethral exudate or intraurethral swab specimen should be performed to diagnose urethritis and presumptively identify gonococcal infection, as recommended by the CDC 1
Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis should be performed on intraurethral swab or first-void urine, as recommended by the CDC 1, 2
Examination of first-void urine for leukocytes should be performed if urethral Gram stain is negative, as recommended by the CDC 1
Syphilis serology and HIV counseling and testing should be performed, as recommended by the CDC 1, 2

The CDC recommends ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days as the initial treatment for epididymitis 1, 2
Bed rest and scrotal elevation are recommended as adjunctive measures, as suggested by the CDC 2
Analgesics should be administered until fever and local inflammation subside, as recommended by the CDC 1, 2

Patients should be reevaluated if symptoms do not improve within 3 days of starting treatment, as recommended by the CDC 1, 2
Persistent swelling or tenderness after completing antimicrobial therapy requires comprehensive evaluation, as recommended by the CDC 1
Differential diagnosis for persistent symptoms includes tumor, abscess, infarction, testicular cancer, and tuberculous or fungal epididymitis, as reported by the CDC 2

Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset, as recommended by the CDC 1, 2
Patients should avoid sexual intercourse until they and their partners complete therapy and are asymptomatic, as recommended by the CDC 1, 2

For patients allergic to cephalosporins and/or tetracyclines, ofloxacin 300 mg orally twice a day for 10 days or levofloxacin 500 mg orally once daily for 10 days can be used as alternative treatments, as recommended by the CDC 1, 2
Hospitalization should be considered when severe pain suggests other diagnoses, patient is febrile, or concerns about medication compliance exist, as recommended by the CDC 1, 2
Patients with uncomplicated epididymitis who are HIV-positive should receive the same treatment regimen as HIV-negative patients, as recommended by the CDC 1, 2
Fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients, as reported by the CDC 1, 2