Specific Organisms and Therapeutic Regimens
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