Epididymo-orchitis Empiric Therapy

Updated: Sep 14, 2019
  • Author: Yagil Barazani, MD; Chief Editor: Thomas E Herchline, MD  more...
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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:

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:

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