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Initial treatment for epididymitis includes analgesics, scrotal support, elevation,
and bed rest. Antibiotic use depends on the suspected etiology. In sexually active
adolescent males, in whom the most likely cause is chlamydia and gonorrhea,
ceftriaxone (250 mg IM in single dose) plus doxycycline (100 mg PO twice a day
for 7 days) or azithromycin (1 g PO once) is recommended. Due to increasing N.
gonorrhea resistance, quinolones are not recommended for routine treatment.
Patients allergic to cephalosporins and/or tetracyclines, or in whom enteric
organisms are suspected, can be treated with fluoroquinolones such as ofloxacin
or levofloxacin. Of note, doxycycline use in younger children has been liberalized
and can be administered for short durations (i.e., 21 days or less) without regard
to the patient age. Fluoroquinolones should not be used routinely as first-line
agents in children younger than 18 years unless there is presence of a complicated
urinary tract infection or no other alternatives exist. In prepubertal boys
epididymitis is most often viral or idiopathic. Those with pyuria, positive urine
cultures, or risk factors for urinary tract infection should be treated with antibiotic
coverage for enteric organisms, such as trimethoprim-sulfamethoxazole or
cephalexin. The patient should be warned that this process is frustratingly slow to
resolve and discomfort and scrotal swelling will gradually subside over a few
weeks.
At any age when epididymitis is associated with a urinary tract infection and in
all prepubertal boys with bacterial epididymitis, referral for urologic follow-up to
rule out a structural problem is recommended.