Epididymo-orchitis Organism-Specific Therapy

Organism-specific therapeutic regimens for epididymo-orchitis are provided below, including those for Escherichia coli, Klebsiella species, and other enteric organisms; Chlamydia trachomatis; and Neisseria gonorrhoeae. ^{[1, 2, 3, 4]} Special considerations ^{[1, 2, 1, 5, 6]} are also provided.

Centers for Disease Control and Prevention guideline recommendations

For acute epididymitis most likely caused by Chlamydia or N gonorrhoeae:

• Ceftriaxone 500 mg IM (1 g, in patients weighing ≥150 kg) in a single dose plus
• Doxycycline 100 mg PO BID for 7 d

For acute epididymitis most likely caused by Chlamydia or N gonorrhoeae, or enteric organisms (eg, in men who practice insertive anal sex):

• Ceftriaxone 500 mg IM (1 g, in patients weighing ≥150 kg) in a single dose plus
• Levofloxacin500 mg orally once daily for 10 days

For acute epididymitis most likely caused by enteric organisms only:

• Levofloxacin 500 mg orally once daily for 10 days

E coli, Klebsiella species, other enteric organisms

Antimicrobial regimens for these organisms include the following:

• Ciprofloxacin 500 mg PO BID for 10 d or
• Levofloxacin 500 mg PO once daily for 10 d or
• Ofloxacin 400 mg PO BID for 10 d or
• Trimethoprim-sulfamethoxazole (160 mg/800 mg) DS one tablet PO BID for 10 d or
• Amoxicillin-clavulanate 500-875 mg PO BID (or 15-20 mg/kg PO q12h) for 10 d

C trachomatis

Antimicrobial regimens for Chlamydia include the following ^[4] :

• Doxycycline 100 mg PO BID for 7 d

Alternative regimens for Chlamydia include the following ^[4] :

• Azithromycin 1 g PO in a single dose or
• Levofloxacin 500 mg PO once daily for 7 days

N gonorrhoeae

Antimicrobial regimens for gonorrheal infections include the following ^[3] :

• Ceftriaxone 500 mg IM (1 g, in patients weighing ≥150 kg) in a single dose plus
• Azithromycin 1 g PO in a single dose
• If ceftriaxone is not available, cefixime, 400 mg orally in a single dose, can be substituted in combination therapy
• In patients with cephalosporin allergy, gentamicin 240 mg IM in a single dose plus azithromycin 2 g orally in a single dose
• Fluoroquinolones are not recommended to treat gonococcal infections unless susceptibility testing is performed

Special considerations

See the list below:

• Midstream urine cultures and Gram stains are useful to guide therapy
• Urinalysis findings are positive for pyuria in only 25% of patients, and urine may be sterile in 40-90% of patients
• Obtain a urethral swab culture (before void, after prostate massage) for gonorrheal and chlamydial infections if the patient is sexually active
• Use imaging studies, particularly Doppler ultrasonography, to help distinguish acute epididymitis from the more ominous testicular torsion
• Use ultrasonography to help detect a scrotal abscess as well as complications of epididymitis and bacterial or pyogenic orchitis ^[7]
• Urine coliforms are grown in culture to determine speciation
• Persistent symptoms or inadequate treatment can result in chronic epididymitis or abscess

Adjunctive therapy

If there is concern for sexually transmitted diseases such as infections with C trachomatis or N gonorrhoeae:

• The patient’s sexual partners should be evaluated and treated
• The patient should abstain from sexual relations until 7d after single-dose therapy or until completion of a 7-d regimen

Supportive therapy:

• Reduce physical activity; provide scrotal support and elevation; use ice packs, anti-inflammatory agents, and analgesics, including nerve blocks; avoid urethral instrumentation; use sitz baths