Version July 2025
INTRODUCTION —
Acute epididymitis, or inflammation of the epididymis, is one of the most common causes of acute scrotal pain. The pain is typically unilateral, with associated testicular swelling and tenderness. Among patients with epididymal inflammation, up to 58 percent also have inflammation of the testis, known as epididymo-orchitis [1]. As the evaluation and management of acute epididymo-orchitis is similar to that of acute epididymitis [2], we will refer only to acute epididymitis in this topic.
This topic addresses the clinical manifestations, diagnosis, and treatment of acute infectious epididymitis in adults. Noninfectious causes generally present as subacute or chronic epididymitis and are discussed separately. The clinical evaluation of acute scrotal pain in adults, chronic epididymitis, and the evaluation and treatment of acute epididymitis in children and adolescents are also discussed separately:
●Acute scrotal pain in adults (see "Acute scrotal pain in adults: Evaluation and management of major causes")
●Subacute and chronic epididymitis (see "Nonacute scrotal conditions in adults", section on 'Chronic epididymitis')
●Chronic epididymitis in adults (see "Nonacute scrotal conditions in adults", section on 'Chronic epididymitis')
●Acute epididymitis in children and adolescents (see "Causes of scrotal pain in children and adolescents", section on 'Epididymitis')
The discussion in this topic is consistent with the Sexually Transmitted Infections Treatment Guidelines from the United States Centers for Disease Control and Prevention [1].
EPIDEMIOLOGY —
Acute epididymitis is the most common cause of scrotal pain in adults in the outpatient setting, accounting for 600,000 cases per year in the United States [2]. In one series, 43 percent of epididymitis cases were among patients 20 to 39 years of age, and 29 percent of cases were among patients 40 to 59 years of age [3].
ETIOLOGY AND RISK FACTORS —
Acute epididymitis is most commonly infectious in etiology, caused by both sexually transmitted pathogens and non-sexually transmitted pathogens (table 1) [3]. Noninfectious epididymitis is associated with trauma, autoimmune disease, or amiodarone use. These typically present as subacute or chronic epididymitis [4] and are discussed separately. (See "Nonacute scrotal conditions in adults", section on 'Chronic epididymitis'.)
●Sexually transmitted acute epididymitis – Acute epididymitis is most commonly caused by sexually transmitted pathogens in sexually active males, particularly younger patients and those with no history of obstructive uropathy or other risk factors for epididymitis secondary to urinary tract infection (table 1) [3,5,6]. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common organisms, although Ureaplasma urealyticum and Mycoplasma genitalium have also been associated with epididymitis.
Patients who engage in insertive, unprotected anal intercourse are also at increased risk for acute bacterial epididymitis caused by enteric bacteria.
In patients with human immunodeficiency virus (HIV) or other immunocompromising conditions, epididymitis may also be caused by cytomegalovirus, toxoplasmosis, other Mycoplasma species, and other bacterial and viral pathogens [7].
●Acute epididymitis secondary to urinary tract infection – Acute epididymitis that is not sexually transmitted is typically secondary to infection of the urinary tract with Escherichia coli, other enteric bacteria, and Pseudomonas species (table 1). Risk factors include a history of benign prostatic hyperplasia, obstructive uropathy, neurogenic bladder, recent urologic instrumentation, or any other condition that facilitates the retrograde flow of urinary bacteria into the ejaculatory duct. These conditions occur most commonly in older patients [3].
Other, less common organisms responsible for acute epididymitis include mumps, Mycobacterium tuberculosis, and Brucella species.
CLINICAL MANIFESTATIONS —
Patients with acute epididymitis present with unilateral scrotal pain that worsens over several days. Palpable swelling of the epididymis is usually evident. The scrotum may be diffusely painful, with maximal tenderness along the posterior aspect of the testis (figure 1). As the inflammation progresses, symptoms may extend to the ipsilateral spermatic cord and testicle, occasionally with an associated reactive hydrocele. Infrequently, both testicles may become involved [8].
Acute epididymitis may occur in isolation or in conjunction with urethritis or prostatitis. Symptoms of urethritis include dysuria, urinary frequency, and urethral discharge. Patients with concomitant acute prostatitis are typically acutely ill, with fever, chills, and myalgia in addition to irritative urinary symptoms and voiding symptoms ranging from hesitancy to acute urinary retention. These conditions are discussed separately. (See "Acute bacterial prostatitis", section on 'Clinical manifestations' and "Urethritis in adults and adolescents", section on 'Clinical manifestations'.)
Most cases of acute epididymitis are unilateral. Bilateral scrotal involvement suggests mumps epididymo-orchitis, especially in the setting of an outbreak. In such cases, parotitis may also be present. (See "Mumps", section on 'Clinical manifestations'.)
Acute onset scrotal pain that escalates over hours is uncommon and should prompt consideration of other causes of acute scrotal pain, as below. (See 'Differential diagnosis' below and "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'Identification of urgent conditions'.)
DIFFERENTIAL DIAGNOSIS —
The primary differential diagnosis of acute scrotal pain includes necrotizing fasciitis (Fournier's gangrene), testicular torsion, and acute epididymitis (table 2). Necrotizing fasciitis and testicular torsion are surgical emergencies that require prompt identification and escalation of care. Systemic illness and rapidly progressive erythema, crepitus, and edema or necrosis of the overlying soft tissues of the scrotum strongly suggest necrotizing fasciitis (picture 1). Sudden onset or intermittent scrotal pain in the absence of urethritis symptoms and a horizontal-appearing testis on examination suggests testicular torsion (figure 2). Evaluation of these conditions is discussed separately. (See "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'Patient evaluation'.)
Less common and less urgent etiologies of acute scrotal pain may also be considered, including torsion of the appendix testis, hernia, testicular cancer, and other causes, especially if the clinical presentation and laboratory evaluation are not suggestive of acute epididymitis. (See "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'Other etiologies of acute scrotal pain'.)
Noninfectious causes of epididymitis generally present as subacute or chronic epididymitis and are discussed separately. (See "Nonacute scrotal conditions in adults", section on 'Chronic epididymitis'.)
DIAGNOSTIC APPROACH
History and examination — A detailed sexual history and genital examination should be performed to evaluate for acute epididymitis while ruling out necrotizing fasciitis and testicular torsion. Key features suggestive of acute epididymitis are reviewed here. A comprehensive approach to the evaluation of acute scrotal pain is presented in the algorithm (algorithm 1) and discussed in detail separately. (See "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'History' and "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'Physical examination'.)
●History – Key historical features suggestive of acute epididymitis include the following:
•Gradual onset of unilateral testicular pain over several days.
•Pain localized to the posterior aspect of the testis.
•Dysuria or discharge suggests genitourinary infection.
Patients should be asked about sexual activity, including insertive anal intercourse. They should also be asked about lower urinary tract symptoms suggestive of benign prostatic hyperplasia or obstructive uropathy and recent urologic instrumentation, as these historical features guide empiric antimicrobial selection. (See 'Antibiotic therapy' below.)
●Physical examination
•Visual inspection – The abdomen, inguinal region, and scrotal skin and contents should be carefully examined (figure 1). Visual inspection may reveal overlying erythema of the scrotal wall and testicular swelling.
•Palpation – On palpation, the epididymis is diffusely tender and swollen, with maximal tenderness along the posterior aspect. When prolonged, swelling may progress to include the spermatic cord and/or the entire testicle.
•Evaluation for adjacent infections – Epididymitis may occur in association with urethritis or prostatitis. When concomitant urethritis is present, urethral discharge may be evident and should be sent for laboratory testing, as below. If concomitant prostatitis is suspected, a gentle digital rectal examination should be performed. An edematous or tender prostate on physical examination in this setting is highly suggestive of acute bacterial prostatitis. Diagnosis and management of acute bacterial prostatitis are discussed elsewhere. (See "Acute bacterial prostatitis".)
•Cremasteric reflex – If performed, the cremasteric reflex is often positive (the testis pulls up when the ipsilateral thigh is touched) in patients with acute epididymitis. (See "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'Patient evaluation'.)
Laboratory testing — In all suspected cases of acute epididymitis, we perform the following studies to detect inflammation, confirm a pathogen, and screen for associated conditions. First-catch urine (eg, the initial 10 to 15 mL of the urine stream, ideally without precleaning or voiding in the prior hour) provides the optimal sample for urine studies, including urine nucleic acid amplification testing (NAAT):
•Urinalysis and microscopy
•Urine culture
•Urine NAAT for C. trachomatis and N. gonorrhoeae
•Serologic testing for syphilis and HIV
If point-of-care testing is available, a specimen for Gram stain may be collected from urethral discharge to rapidly identify white blood cells suggestive of inflammation. Occasionally, intracellular gram-negative diplococci indicative of N. gonorrhoeae or other Neisseria species may be seen [9]. While urine NAAT should still be obtained, the point-of-care approach has the advantage of prompt diagnosis. The approach to point-of-care diagnostic testing is similar to the diagnostic approach used for urethritis (algorithm 2). (See "Urethritis in adults and adolescents", section on 'Diagnosis'.)
Role of testicular ultrasound — In classic cases of epididymitis with compatible history, examination, and urine studies, confirmatory ultrasound is not required for diagnosis. (See 'Establishing the diagnosis' below.)
We perform testicular ultrasound in patients with equivocal or ambiguous presentations. Doppler ultrasound has a high sensitivity for diagnosing epididymitis and epididymo-orchitis. Findings may include epididymal inflammation and associated scrotal fluid/reactive hydrocele, scrotal wall thickening, and testicular involvement [10]. In one study, Doppler ultrasonography had a sensitivity and specificity of 70 and 88 percent, respectively, for the diagnosis of epididymitis in patients with acute onset scrotal pain [11].
Establishing the diagnosis — A presumptive diagnosis of acute epididymitis should prompt initiation of empiric therapy. The diagnosis is subsequently confirmed through the combination of response to therapy and laboratory testing results.
●Presumptive diagnosis – A presumptive diagnosis of acute epididymitis is supported by acute scrotal pain and swelling, with maximal tenderness at the posterior aspect of the testis, in the absence of features suggestive of necrotizing fasciitis or testicular torsion.
If point-of-care testing is performed, a positive leukocyte esterase on urine dipstick or >10 white blood cells per high power field on microscopic examination of first-catch urine also supports a diagnosis of urethritis. When accompanied by scrotal pain and swelling, this finding is strongly suggestive of acute epididymitis.
Empiric therapy is initiated in patients with a presumptive clinical diagnosis while confirmatory laboratory testing (urine NAAT and urine culture) is pending. A positive clinical response to empiric antibiotics for typical pathogens supports the presumptive diagnosis of acute epididymitis. (See 'Antibiotic therapy' below.)
●Diagnostic confirmation – Any of the following results establish the diagnosis of acute epididymitis:
•Positive NAAT for C. trachomatis or N. gonorrhoeae.
•Positive urine culture for a genitourinary pathogen; a positive urine culture is especially useful when diagnosing epididymitis secondary to urinary tract infection and epididymitis in patients who engage in insertive anal intercourse.
•Gram-negative diplococci inside polymorphonuclear neutrophils on stain of urethral secretions. This finding suggests Neisseria infection, most commonly N. gonorrhoeae, though in rare cases, other Neisseria species, including Neisseria meningitidis can also cause urethritis (picture 2).
However, negative urine culture and microbiologic testing do not exclude the diagnosis of epididymitis. In such patients, response to empiric antibiotic therapy is the primary method of diagnostic confirmation. (See 'Antibiotic therapy' below.)
MANAGEMENT
Supportive care — Nonsteroidal anti-inflammatory drugs and local application of ice can be used as needed for pain and swelling. Scrotal elevation using a rolled-up towel and scrotal support wear (ie, avoiding boxers) may also help to alleviate discomfort.
Inpatient care may be warranted for patients with severe pain, fever, hemodynamic instability, scrotal abscess, and other signs of systemic illness. (See 'Severe infection' below.)
Antibiotic therapy — Empiric antimicrobial treatment is based on most likely pathogens, as outlined in the algorithm (algorithm 3).
Sexually active patients — All sexually active adults are at risk for sexually transmitted acute epididymitis. We determine empiric treatment based on the patient's sexual practices and concomitant risk for epididymitis secondary to urinary tract infection (UTI), including recent urologic instrumentation, benign prostatic hyperplasia, neurogenic bladder, or other obstructive uropathy (algorithm 3):
●No insertive anal intercourse and no risk factors for UTI – For patients who do not engage in insertive anal intercourse and have not had recent urologic instrumentation or symptoms of obstructive uropathy, we suggest treatment with ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if the patient weighs 150 kg or greater) plus doxycycline (100 mg orally twice a day for 10 days) for coverage of N. gonorrhoeae and C. trachomatis, respectively [7]. This regimen also covers some less common pathogens associated with epididymitis, including Ureaplasma spp and some Mycoplasma spp.
For patients unable to tolerate doxycycline, a regimen of ceftriaxone and a single azithromycin dose (1 g orally) is an alternative option, though doxycycline results in superior microbiologic cure rates when compared with azithromycin for treatment of C. trachomatis [12]. (See "Treatment of Chlamydia trachomatis infection in adults and adolescents", section on 'Doxycycline as preferred agent'.)
For patients with severe allergies that preclude cephalosporin use, alternative regimens for treatment of N. gonorrhoeae are discussed separately. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Penicillin-allergic patients'.)
●History of insertive anal intercourse and/or risk factors for UTI – For patients who engage in insertive anal intercourse and for patients with recent urologic instrumentation or symptoms of obstructive uropathy, we suggest treatment with ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if the patient weighs 150 kg or greater) plus levofloxacin 500 mg orally once daily for 10 days for coverage of N. gonorrhoeae, C. trachomatis, and gram-negative bacteria (eg, E. coli).
With this regimen, ceftriaxone covers gonorrhea, while levofloxacin has good activity against chlamydia, enteric pathogens, and less common pathogens associated with epididymitis, including Ureaplasma spp and some Mycoplasma spp. Although not typically used for chlamydia, levofloxacin is an appropriate antichlamydial option when coverage for other pathogens is warranted, as in this situation.
Fluoroquinolones alone are not recommended for the treatment of acute epididymitis if gonorrhea is suspected because of the widespread resistance of N. gonorrhoeae to this class of drugs. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Fluoroquinolones'.)
These treatment regimens are in accordance with the Sexually Transmitted Infections Treatment Guidelines from the United States Centers for Disease Control and Prevention [1]. Studies defining the optimal antimicrobial regimens for acute epididymitis are limited, and the selection of drugs is based on treatment evidence for other types of infections with these pathogens. Additional details regarding the diagnosis and management of individual pathogens are discussed separately:
●(See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)
●(See "Treatment of Chlamydia trachomatis infection in adults and adolescents".)
●(See "Mycoplasma genitalium infection".)
Patients who are not sexually active — In patients who are not sexually active, we suggest initial therapy with levofloxacin 500 mg orally once daily for 10 days or trimethoprim-sulfamethoxazole, one double-strength tablet twice daily for 10 days (algorithm 3). These empiric regimens target enteric gram-negative bacteria (eg, E. coli), which are more likely to be the cause of epididymitis secondary to UTI. (See 'Etiology and risk factors' above.)
Severe infection — Rarely, patients with epididymitis can present with severe pain, fever, testicular abscess, or hemodynamic instability. These patients warrant hospitalization for intravenous antibiotics and intravenous hydration (algorithm 3). Empiric antimicrobial selection is guided by risk of sexually transmitted infection and/or UTI:
●For sexually active patients – We recommend ceftriaxone 1 g intravenously every 24 hours plus doxycycline 100 mg orally twice daily to prioritize coverage for sexually transmitted infections. (See 'Sexually active patients' above.)
●For patients who are not sexually active – We recommend ceftriaxone 1 g intravenously every 24 hours or a fluoroquinolone (eg, levofloxacin 500 mg daily or ciprofloxacin 400 mg every 12 hours) as an empiric regimen that covers E. coli and other gram-negative bacteria.
If resistant organisms are a concern (table 3), the approach and empiric antibiotic regimens are similar as for individuals with acute complicated UTI. (See "Acute complicated urinary tract infection (including pyelonephritis) in adults", section on 'High risk of MDR infection'.)
We treat with intravenous therapy until afebrile for 24 hours then switch to an oral regimen based on urine culture and sensitivity results, for a total antibiotic duration of 10 to 14 days. If C. trachomatis was not identified on nucleic acid amplification testing, doxycycline may be discontinued. If the patient fails to improve on therapy after 48 hours, we obtain a scrotal ultrasound to evaluate for scrotal abscess. (See 'Assessment of therapeutic response' below.)
Patients with concomitant prostatitis may warrant a prolonged course of antimicrobial therapy. (See "Acute bacterial prostatitis", section on 'Antimicrobial therapy'.)
Counseling on sexual activity — Patients should be counseled to abstain from sexual activity until symptoms resolve, antibiotic treatment is completed, and partners have been evaluated and treated to decrease risk of transmission and reinfection. (See 'Partner management and retesting' below.)
FOLLOW-UP
Assessment of therapeutic response
Expected clinical course — Pain and urethritis symptoms should improve on appropriate antibiotic therapy within 48 to 72 hours of treatment initiation. Resolution of testicular swelling may take up to six weeks with appropriate therapy.
Patients with symptom improvement
●If laboratory studies identify a pathogen – Positive results on a urine culture may allow the clinician to tailor antimicrobial therapy, including consideration of antimicrobial resistance and identification of other organisms inadequately treated by the empiric regimen.
If nucleic acid amplification tests (NAAT) for C. trachomatis and N. gonorrhoeae are positive and the patient was not treated for sexually transmitted epididymitis, the antibiotic regimen should be revised accordingly, and sexual partners should be tested. (See 'Sexually active patients' above and 'Partner management and retesting' below.)
●If laboratory studies do not identify a pathogen – Patients with symptomatic improvement on empiric antibiotic therapy and unidentified etiology after NAAT and urine culture results should complete the empiric treatment course as above.
For patients who had severe infection, some UpToDate authors repeat scrotal ultrasound after resolution of symptoms to evaluate for underlying testicular mass.
Patients with persistent symptoms — Persistent symptoms or lack of response to empiric therapy warrant additional evaluation.
●Persistent testicular pain or urethritis symptoms – These patients should be retested for C. trachomatis and N. gonorrhoeae and evaluated for less common pathogens. M. genitalium and Ureaplasma spp are increasingly recognized causes of urethritis and epididymitis that require specific NAAT for identification and may require alternative antibiotics, such as moxifloxacin [13]. (See "Mycoplasma pneumoniae infection in adults" and "Mycoplasma hominis and Ureaplasma infections".)
A testicular ultrasound should also be performed to evaluate for scrotal abscess. If ultrasound results are equivocal, additional laboratory studies do not reveal a pathogen, and diagnostic uncertainty persists, urologic consultation is indicated to assist with diagnosis of alternate etiologies of scrotal pain [14-16]. (See 'Differential diagnosis' above and "Acute scrotal pain in adults: Evaluation and management of major causes", section on 'Other etiologies of acute scrotal pain'.)
●Persistent testicular swelling – Testicular swelling may take up to six weeks to resolve; therefore, persistent edema to this point does not warrant additional evaluation. However, if swelling persists beyond six weeks, a testicular ultrasound should be performed to evaluate for mass or structural abnormality.
Partner management and retesting — Partners should be tested for N. gonorrhoeae and C. trachomatis. Details are reviewed separately. (See "Treatment of Chlamydia trachomatis infection in adults and adolescents", section on 'Management of sex partners' and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Management of sexual partners'.)
Reinfection with the specific sexually transmitted pathogens that cause acute epididymitis is common. Patients who are diagnosed with N. gonorrhoeae or C. trachomatis epididymitis should be retested in several months to identify reinfection and reduce the risk of continued transmission. (See "Treatment of Chlamydia trachomatis infection in adults and adolescents", section on 'Follow-up testing' and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Patient follow-up'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexually transmitted infections".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Epididymitis and orchitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Etiology and risk factors – Acute infectious epididymitis is a frequent cause of acute scrotal pain.
In sexually active patients, Neisseria gonorrhoeae and Chlamydia trachomatis are the most common organisms responsible for acute epididymitis. Patients who engage in insertive anal intercourse are also at risk for acute bacterial epididymitis from enteric bacteria.
Epididymitis may also arise secondary to urinary tract infection (UTI), most commonly caused by Escherichia coli and other enteric bacteria. Risk factors for epididymitis secondary to UTI include recent urologic procedure, benign prostatic hyperplasia, neurogenic bladder, or other obstructive uropathy. (See 'Epidemiology' above and 'Etiology and risk factors' above.)
●Clinical manifestations – Gradual onset of unilateral scrotal pain over several days is the primary complaint. The scrotum may be diffusely painful and swollen, with maximal tenderness along the posterior aspect of the testis (figure 1). When concomitant urethritis or prostatitis is present, patients may also report dysuria, urethral discharge, or irritative urinary symptoms. (See 'Clinical manifestations' above.)
●Differential diagnosis – The primary differential diagnosis of acute scrotal pain includes necrotizing fasciitis, testicular torsion, and acute epididymitis (table 2). The general approach to acute scrotal pain is reviewed in the algorithm (algorithm 1) and discussed separately. (See "Acute scrotal pain in adults: Evaluation and management of major causes".)
●Establishing the diagnosis – A presumptive diagnosis of acute epididymitis is supported by unilateral scrotal pain and swelling, with maximal tenderness at the posterior aspect of the testis, in the absence of features suggestive of necrotizing fasciitis or testicular torsion (algorithm 1).
The diagnosis is confirmed with a positive nucleic acid amplification test for N. gonorrhoeae or C. trachomatis, positive urine culture for a genitourinary pathogen, or response to empiric therapy if microbiologic testing is negative. (See 'Establishing the diagnosis' above.)
Empiric therapy is initiated pending the results of microbiologic testing.
•Empiric therapy for sexually active patients – For patients who are sexually active, we determine empiric treatment based on the patient's sexual practices and risk for UTI (ie, history of recent urologic procedure or obstructive uropathy) (algorithm 3) (see 'Sexually active patients' above):
-No insertive anal intercourse and no risk factors for UTI – For patients with no insertive anal intercourse and no risk factors for urinary tract infection (UTI), we suggest ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if the patient weighs 150 kg or greater) plus doxycycline (100 mg orally twice a day for 10 days) (Grade 2C). Ceftriaxone plus azithromycin (1 g orally in one dose) is a second-line regimen in patients unable to tolerate doxycycline. These regimens provide appropriate coverage for N. gonorrhoeae and C. trachomatis.
-History of insertive anal intercourse and/or risk factors for UTI – For patients with insertive anal intercourse and/or risk factors for UTI, we suggest ceftriaxone (500 mg intramuscular injection in one dose, or 1 g if the patient weighs 150 kg or greater) plus levofloxacin 500 mg orally once daily for 10 days (Grade 2C). These regimens provide appropriate coverage for N. gonorrhoeae, C. trachomatis, and gram-negative bacteria (eg, E. coli). Although not typically used for C. trachomatis, levofloxacin is an appropriate antichlamydial option when coverage for other pathogens is warranted.
•Empiric therapy for patients who are not sexually active – For patients who are not sexually active, we suggest levofloxacin 500 mg orally once daily for 10 days or trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 10 days) (Grade 2C). These regimens provide adequate coverage for gram-negative bacteria (eg, E. coli) (algorithm 3). (See 'Patients who are not sexually active' above.)
●Supportive care – Most cases of epididymitis can be treated on an outpatient basis with oral antibiotics, nonsteroidal anti-inflammatory drugs, and local application of ice. Scrotal elevation using a rolled-up towel and scrotal support wear (eg, avoiding boxers) may also help to alleviate discomfort. (See 'Supportive care' above.)
●Expected clinical course – Patients with acute epididymitis should improve within 48 to 72 hours of starting appropriate antibiotic therapy. Resolution of testicular swelling may take up to six weeks.
Patients with symptomatic improvement should complete the empiric antibiotic course. When urine culture results are positive, they may guide further tailoring of antimicrobial therapy.
Further evaluation is indicated for patients with persistent or worsening symptoms on antibiotic therapy, including additional testing for less common pathogens, testicular ultrasound, or urology referral. (See 'Assessment of therapeutic response' above.)
●Retesting and partner management – Sexual partners should be tested for N. gonorrhoeae and C. trachomatis. Patients should be counseled to abstain from sexual activity until symptoms resolve, antibiotic treatment is completed, and partners have been evaluated and treated. (See 'Counseling on sexual activity' above.)
Patients diagnosed with N. gonorrhoeae or C. trachomatis epididymitis should be retested in several months because of the high rate of reinfection. (See 'Partner management and retesting' above.)
