Treatment of Epididymitis and Orchitis

• may be bacterial, nonbacterial, noninfectious, or idiopathic in origin.
• Bacterial epididymo-orchitis tends to be caused by either urinary tract pathogens or by a sexually transmitted pathogen
• Empiric antibiotic therapy is recommended only for presumed bacterial epididymitis and should be started before microbiological identification of the pathogen.

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
• If a STI is suspected, advise the patient to use condoms or abstain from sex for 7 days after treatment is initiated
• 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
• 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 males with suspected infection with enteric organisms

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

Adjunctive/supportive therapy

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

References:

1. http://emedicine.medscape.com/article/2018356-overview
2. http://www.cdc.gov/std/treatment/2010/epididymitis.htm