Epididymitis: The Daily PANCE Blueprint
A sexually active 28-year-old man has three days of gradually worsening left scrotal pain, along with dysuria and a scant urethral discharge. His temperature is 38.0°C. The left epididymis is swollen and tender, the testis itself is normal in position and lie, the cremasteric reflex is present, and elevating the scrotum relieves his pain. Urinalysis shows pyuria. Which of the following is the most appropriate treatment?
A. IM ceftriaxone plus oral doxycycline
B. Oral levofloxacin alone
C. Immediate surgical exploration
D. Scrotal support and NSAIDs alone
E. Oral fluconazole
Answer and topic summary
The answer is A. IM ceftriaxone plus oral doxycycline
Gradual-onset scrotal pain with a tender, swollen epididymis, an intact cremasteric reflex, and relief on elevation is acute epididymitis — not torsion. In a sexually active man under 35, the organisms to cover are Chlamydia trachomatis and Neisseria gonorrhoeae, so the regimen is a single dose of IM ceftriaxone plus 10 days of oral doxycycline, with partner treatment. A fluoroquinolone alone is the right choice only for older men or those with insertive anal intercourse, where enteric organisms like E. coli dominate — it does not reliably cover gonorrhea. The critical distinction is testicular torsion, which comes on abruptly, produces a high-riding testis with a horizontal lie, abolishes the cremasteric reflex, and is not relieved by elevation; that is a surgical emergency with a six-hour window. When the exam is equivocal, get a color Doppler ultrasound.
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