Treatment for epididymitis depends on the likely pathogens responsible and testicular torsion must be confidently excluded prior to treatment. National guidelines developed by British Association for Sexual Health and HIV (BASHH) recommend(7):

  1. Having a very low threshold for excluding testicular torsion
  2. Rest, Analgesia (NSAIDs) and Scrotal Support
  3. Empirical Antibiotic treatment based on initial assessment whilst awaiting culture results.
  4. If antibiotics are started in ED, a first pass urine should be sent for C. trachomatis and N. Gonorrhoea, as well as a urine dip/mid-stream urine MC&S.
  5. All patients with probable STI should be advised to abstain from sexual intercourse and attend an appropriate sexual health (GUM) clinic for STI testing.

If Sexually-Transmitted infection suspected treatment is typically (young patient, new or multiple sexual partners, lack of consistent condom use, known STI contact):
Ceftriaxone 1g IM single dose, PLUS doxycycline 100mg PO BD for 10-14 days

If an enteric pathogen is likely (older patient, not sexually active, recent instrumentation, urine dipstick positive for leukocytes and nitrites):

Ofloxacin 200mg PO BD for 14 days, OR
Levofloxacin 500mg PO OD for 10 days, OR
Co-amoxiclav 625mg PO TDS for 10 days

Click here for 2019 BASHH guidelines.

If Mumps suspected, antibiotics are not indicated and should be treated as per Mumps: NICE Clinical Knowledge Summary.

Patients with epididymo-orchitis typically can be discharged home and do not require hospital admission unless they are: struggling to manage symptoms; particularly unwell (septic); immunocompromised.

It is important to safety-net patients discharged home. Advise the patient symptoms should begin to improve within 3 days of starting treatment but may persist for up to 6 weeks. If there is persistence of symptoms patients may require a testicular ultrasound +/- specialist urological or sexual health follow-up to ensure the appropriate treatment was given, that an abscess hasn’t developed and that there isn’t an underlying malignancy.

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