What is the role of antibiotics in the treatment of acute epididymitis?

Updated: Apr 04, 2018
  • Author: Michelle DiMare, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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In general, antibiotics should be used in all cases of epididymitis, regardless of a negative urinalysis or the urethral Gram stain result. Nonsteroidal anti-inflammatory agents or narcotic analgesics are also generally prescribed to patients with epididymitis.

However, in one study of epididymitis in 140 boys aged 2 months to 17 years (median, 11 yr), only 5 of 140 patients had a proven bacterial infection. Given this low rate of a bacterial cause, the authors recommend a selective approach to antibiotic therapy in pediatric epididymitis. They suggest treating all young infants, regardless of urinalysis results, and older boys who have a positive urinalysis or culture. It is also recommended to presumptively treat sexually active adolescents with epididymitis for sexually transmitted infections. This study excluded boys with recent urologic surgery and known lower urinary tract anomalies. [20]


Empiric coverage varies with the patient's age and sexual history. Medications include ceftriaxone, doxycycline, levofloxacin, and ofloxacin. [5, 8, 21, 22, 13, 3]

Prepubertal patients and older men require empiric coverage for coliform bacteria (enteric gram-negative bacilli or Pseudomonas). Both of these patient populations may be treated with trimethoprim-sulfamethoxazole.

Sexually active men need empiric coverage for Chlamydia trachomatis and Neisseria gonorrhoeae, usually with ceftriaxone and doxycycline or azithromycin. [23]

Fluoroquinolones are no longer recommended to treat gonorrhea in the United States. This change is based on an analysis of data from the Centers for Disease Control and Prevention’s (CDC’s) Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed an 11-fold increase in the proportion of fluoroquinolone-resistant gonorrhea (QRNG) in heterosexual men. [24] This limits treatment of gonorrhea to drugs in the cephalosporin class. Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.

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