Snapshot A 60-year-old man with a history of benign prostatic hyperplasia presents with one-sided testicular pain and urinary frequency. He also reports pain with urination. Physical exam reveals a swollen right testicle with substantial induration. Urinalysis reveals positive leukocyte esterase and 20 wbc/hpf. He is prescribed antibiotics for epididymitis. Introduction Clinical definition inflammation of epididymis with symptoms of < 6 weeks Epidemiology incidence 25 per 100,000 persons demographics men 18-35 years old risk factors sexual activity bladder outlet obstruction Etiology pathogens from sexually transmitted infections in men less than 35 years of age Neisseria gonorrhoeae Chlamydia trachomatis urinary tract pathogens in men greater than 35 years of age Escherichia coli Pseudomonas aeruginosa Pathogenesis consequence of sexually transmitted disease or urinary tract infection retrograde ascent of pathogen bladder outlet obstruction bacteriuria and subsequent retrograde ascent of pathogen Prognosis resolves with antibiotics Presentation Symptoms testicular pain and often unilateral lower abdominal pain urinary frequency or urgency urinary dysuria Physical exam fever testicular erythema, tenderness, and induration cremasteric reflex intact Prehn's sign decrease in pain with scrotal elevation Imaging Ultrasound indications to rule out testicular torsion findings enlarged and thick epididymis increased blood flow may also find reactive hydrocele Studies Labs urethral swab Gram stain or methylene blue stain showing white blood cells urine positive leukocyte esterase 10 or more wbc/hpf nucleic amplification testing for Chlamydia and Neisseria Differential Testicular torsion absent cremasteric reflex Treatment Medical antibiotics guided by sexual and urologic history drugs ceftriaxone and doxycycline for sexually transmitted diseases fluroquinolones for enteric pathogen Complications Sepsis Testicular atrophy
QUESTIONS 1 of 1 1 Previous Next (M2.RL.15.61) A 31-year-old man with no significant past medical history presents to his primary care provider complaining of right scrotal pain. He states that the pain began 2 days ago and has gradually worsened. He denies burning on urination. On further questioning, he reports two new sexual partners in the past 6 months. Vital signs T 99.8 F, HR 75 bpm, BP 125/80 mmHg, RR 12 rpm. Exam demonstrates a swollen right scrotum that is painful to the touch. Doppler ultrasonography of his right testicle is shown in Figure A. Urinalysis is positive for white blood cells. Of the following choices, which is the next best step? Tested Concept QID: 106402 FIGURES: A Type & Select Correct Answer 1 Ceftriaxone and doxycycline 64% (25/39) 2 Levofloxacin 5% (2/39) 3 Supportive care and MMR vaccine 10% (4/39) 4 Referral to urologist 13% (5/39) 5 CT abdomen and pelvis 3% (1/39) M 7 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept