Empiric Therapy Regimens

General recommendations and empiric therapeutic regimens for epididymo-orchitis are provided below. Guidelines are based on epidemiology and therefore the appropriate choice of antibiotics requires a clinical assessment of the most likely etiology. The following are summarized below^{[1, 2, 3, 4, 5]}:

Treatment in young sexually active men with suspected sexually transmitted infection
Treatment for suspected enteric organisms by age group
Adjunctive/supportive therapy

General recommendations:

Acute epididymo-orchitis may be bacterial, nonbacterial, noninfectious, or idiopathic in origin.^[6]Bacterial epididymo-orchitis tends to be caused by either urinary tract pathogens or by a sexually transmitted pathogen.^[7]

Empiric antibiotic therapy is recommended only for presumed bacterial epididymitis and should be started before microbiological identification of the pathogen.^[7]

Epididymo-orchitis from sexually transmitted infection (STI)

STI-associated epididymo-orchitis is more likely in men younger than 35 years with more than one partner in the past 12 months, particularly if urethral discharge is present.^[8]

Treatment is aimed at eradication of Neisseria gonorrhoeae and Chlamydia trachomatis and consists of the following:

Ceftriaxone 250-500 mg IM once plus
Azithromycin 1 g PO once or
Substitute doxycycline 100 mg PO BID for 7-14 days for the azithromycin

Note that the dose of ceftriaxone has been increased from 125 mg (US guidelines) and 250 mg (European, New Zealand guidelines) that were recommended in earlier guidelines, owing to increased resistance of N gonorrhoeae to ceftriaxone.^{[7, 9, 10]}

If a STI is suspected, advise the patient to use condoms or abstain from sex for 7 days after treatment is initiated.^[8]Sexual partners should be referred for evaluation and treatment to eliminate the possibility of reinfection.

Epididymo-orchitis from urinary pathogens

Epididymo-orchitis due to infection with gram-negative enteric organisms is most likely in men older than 35 years with a low-risk sexual history, with recent urological instrumentation or urinary tract infection, or with positive urine dipstick for leukocytes and nitrites. If an enteric organism is suspected, fluoroquinolones are the preferred antibiotic, as they have excellent penetration into the testes.^{[7, 11]}Recommended regimens include the following:

Ciprofloxacin 500 mg PO BID for 10-14d or
Levofloxacin 500 mg PO daily for 10d or
Ofloxacin 200 mg PO BID for 14d or
Trimethoprim-sulfamethoxazole (160/800 mg) one DS tablet PO BID for 10d or
Amoxicillin-clavulanate 500 mg TID for 10d

Prepubertal boys with suspected infection with enteric organisms

Options include the following:

Trimethoprim-sulfamethoxazole 3-6 mg/kg PO q12h for 10d or
Amoxicillin-clavulanate 15-20 mg/kg PO q12h for 10d

Adjunctive/supportive therapy

Approaches include the following:

Reduce physical activity
Scrotal support and elevation
Ice packs
Anti-inflammatory agents
Analgesics, including nerve blocks
Sitz baths
Avoid urethral instrumentation

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Author

Yagil Barazani, MD Associate Physician, Department of Urology, The Permanente Medical Group

Disclosure: Nothing to disclose.

Coauthor(s)

Christina B Ching, MD Clinical Assistant Professor, Division of Pediatric Urology, Nationwide Children's Hospital

Christina B Ching, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Student Association/Foundation, American Urological Association

Disclosure: Nothing to disclose.

Edmund S Sabanegh, Jr, MD Chairman, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation

Edmund S Sabanegh, Jr, MD is a member of the following medical societies: American Medical Association, American Society of Andrology, Society of Reproductive Surgeons, Society for the Study of Male Reproduction, American Society for Reproductive Medicine, American Urological Association, SWOG

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Chief Editor

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Received research grant from: Regeneron.

Sections Epididymo-orchitis Empiric Therapy
Empiric Therapy Regimens
References

Epididymo-orchitis Empiric Therapy

Empiric Therapy Regimens

General recommendations:

Epididymo-orchitis from sexually transmitted infection (STI)

Epididymo-orchitis from urinary pathogens

Prepubertal boys with suspected infection with enteric organisms

Adjunctive/supportive therapy

References

Tables

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