Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

bacterial infection

1st line – antibiotic therapy

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ACUTE
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bacterial infection
1st line – 

antibiotic therapy

Sexually active males, regardless of age, should be assessed for risk factors for STIs and treated empirically with ceftriaxone and doxycycline to cover gonococcal or chlamydial infection.[15][33]​ For men who practise insertive anal sex, enteric organisms may also be a cause of epidiymitis, and treatment with ceftriaxone and levofloxacin should be given.[15]

In patients where gonorrhea is considered likely (presence of risk factors: a purulent urethral discharge, known contact of a gonorrheal infection, men who have sex with men), the International Union against Sexually Transmitted Infections (IUSTI) European guideline on epididymo-orchitis recommends addition of azithromycin to ceftriaxone and doxycycline.[26]

If infection due to enteric organisms is likely (e.g., recent urinary tract instrumentation, systemic disease, or immunosuppression), the use of levofloxacin is recommended.[15]

If Mycoplasma genitalium testing has been performed, and the organism suspected (e.g., partner who has tested positive for M genitalium) or confirmed, treatment should include the fluoroquinolone moxifloxacin.[26][29][30]

Systemic fluoroquinolone antibiotics, such as moxifloxacin and levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[39] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions. 

Once test results are available, the antibiotics can be adjusted to target the causative organism(s).

Patients should be advised to avoid unprotected sexual intercourse until they and their partner(s) have completed treatment.

Primary options

Gonorrhea/chlamydia suspected

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

and

doxycycline: 100 mg orally twice daily for 10 days

OR

Gonorrhea/chlamydia suspected; gonorrhea likely

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

and

doxycycline: 100 mg orally twice daily for 10 days

and

azithromycin: 1 g orally as a single dose

OR

Gonorrhea/chlamydia/enteric organisms suspected

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

and

levofloxacin: 500 mg orally once daily for 10 days

OR

Enteric organisms suspected

levofloxacin: 500 mg orally once daily for 10 days

OR

M genitalium suspected

moxifloxacin: 400 mg orally once daily for 14 days

Plus – supportive measures

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ACUTE
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bacterial infection
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Bed rest and scrotal elevation are recommended until signs of local inflammation or fever have resolved.

Analgesics such as acetaminophen should be continued until fever and local inflammation subside.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be of benefit.

Nonselective NSAIDs may be added to acetaminophen to reduce pain. The smallest effective dose is used for the shortest possible time or intermittently.

If patients are systemically ill with signs of sepsis, intravenous fluid replacement and initial intravenous antibiotic therapy may be indicated.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: 250-500 mg every 12 hours when required, maximum 1250 mg/day

OR

ibuprofen: 200-400 mg every 4-6 hours when required, maximum 2400 mg/day

amiodarone-induced

1st line – dose reduction or discontinuation of drug

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ACUTE
|
amiodarone-induced
1st line – 

dose reduction or discontinuation of drug

Side effects of amiodarone, including epididymitis, are known to be dose-dependent and duration-dependent.[4]

Signs and symptoms resolve rapidly following dose reduction or cessation of therapy.

Plus – supportive measures

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ACUTE
|
amiodarone-induced
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Bed rest and scrotal elevation are recommended until signs of local inflammation or fever have resolved.

Analgesics such as acetaminophen should be continued until fever and local inflammation subside.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be of benefit.

Nonselective NSAIDs may be added to acetaminophen to reduce pain. The smallest effective dose is used for the shortest possible time or intermittently.

If patients are systemically ill with signs of sepsis, intravenous fluid replacement and initial intravenous antibiotic therapy may be indicated.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: 250-500 mg every 12 hours when required, maximum 1250 mg/day

OR

ibuprofen: 200-400 mg every 4-6 hours when required, maximum 2400 mg/day

underlying vasculitis

1st line – specialist referral to a rheumatologist

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ACUTE
|
underlying vasculitis
1st line – 

specialist referral to a rheumatologist

Vasculitis of the epididymis is rare but can be due to Behçet syndrome or to Henoch-Schönlein purpura. Referral to a rheumatologist is advised to establish the diagnosis and to determine whether epididymal involvement is part of a systemic vasculitic process, and to plan appropriate treatment.

Plus – supportive measures

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ACUTE
|
underlying vasculitis
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Bed rest and scrotal elevation are recommended until signs of local inflammation or fever have resolved.

Analgesics such as acetaminophen should be continued until fever and local inflammation subside.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be of benefit.

Nonselective NSAIDs may be added to acetaminophen to reduce pain. The smallest effective dose is used for the shortest possible time or intermittently.

If patients are systemically ill with signs of sepsis, intravenous fluid replacement and initial intravenous antibiotic therapy may be indicated.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: 250-500 mg every 12 hours when required, maximum 1250 mg/day

OR

ibuprofen: 200-400 mg every 4-6 hours when required, maximum 2400 mg/day

idiopathic or viral

1st line – supportive measures

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ACUTE
|
idiopathic or viral
1st line – 

supportive measures

Bed rest and scrotal elevation are recommended until signs of local inflammation or fever have resolved.

Analgesics such as acetaminophen should be continued until fever and local inflammation subside.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be of benefit.

Nonselective NSAIDs may be added to acetaminophen to reduce pain. The smallest effective dose is used for the shortest possible time or intermittently.

If patients are systemically ill with signs of sepsis, intravenous fluid replacement and initial intravenous antibiotic therapy may be indicated.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

naproxen: 250-500 mg every 12 hours when required, maximum 1250 mg/day

OR

ibuprofen: 200-400 mg every 4-6 hours when required, maximum 2400 mg/day

tuberculous

1st line – antituberculous antibiotics, specialist referral, and supportive measures

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ACUTE
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tuberculous
1st line – 

antituberculous antibiotics, specialist referral, and supportive measures

Tuberculous epididymitis should be treated with systemic antibiotics according to local guidelines, due to highly variable tuberculosis strains and antibiotic resistance patterns.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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