A 43-year-old man seeks care for a painful testicle. The discomfort started 2-3 days ago and has progressed to sharp left testicular pain every time he steps down with his left foot. He has no fever, chills, or dysuria. He has been in a stable monogamous relationship for 20 years and denies anal sexual intercourse. He has not had this problem previously. There is no history of trauma to the area. He considers himself in good health and takes no medications.
His temperature is 37.4 C (99.4 F), blood pressure is 130/80 mm Hg, and pulse is 84/min. Cremasteric reflexes are normal bilaterally. He has no skin lesions involving the genitalia and no palpable inguinal lymph nodes. The scrotum is warm, and the left testicle feels slightly swollen with severe tenderness to palpation, especially over its posterior aspect. There are no inguinal hernias. There is no urethral discharge.
A urinalysis is normal.
Which of the following is the most likely diagnosis?

Question

A 43-year-old man seeks care for a painful testicle.  The discomfort started 2-3 days ago and has progressed to sharp left testicular pain every time he steps down with his left foot.  He has no fever, chills, or dysuria.  He has been in a stable monogamous relationship for 20 years and denies anal sexual intercourse.  He has not had this problem previously.  There is no history of trauma to the area.  He considers himself in good health and takes no medications.
His temperature is 37.4 C (99.4 F), blood pressure is 130/80 mm Hg, and pulse is 84/min.  Cremasteric reflexes are normal bilaterally.  He has no skin lesions involving the genitalia and no palpable inguinal lymph nodes.  The scrotum is warm, and the left testicle feels slightly swollen with severe tenderness to palpation, especially over its posterior aspect.  There are no inguinal hernias.  There is no urethral discharge.
A urinalysis is normal.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_986f_6fa5_853d_df1a5c4e7240_MD0002_00 This patient's presentation is consistent with epididymitis. Epididymitis usually presents with acute onset testicular pain, fever, possible urinary symptoms (e.g., urinary frequency or urgency), and exquisite tenderness on testicular examination. The cremasteric reflex is usually present. Urinalysis can be normal in patients without urinary symptoms. The diagnosis is usually made clinically, but Doppler ultrasound can be done in equivocal cases to document increased flow to the affected epididymis. Chlamydia trachomatis and Neisseria gonorrhoeae are more common in men < age 35, while E. coli is more common in older men and men practicing anal intercourse. Treatment is usually outpatient and consists of testicular elevation, NSAIDs, and antibiotics with close follow-up. < (Choice B) Germ cell tumors usually present with painless testicular swelling and less commonly with testicular pain due to hemorrhage or infarction. (Choice C) Although more common in boys < age 12, testicular torsion can occur in adult men. Testicular torsion is associated with a "high-riding" testicle and absence of the cremasteric reflex. Confirmation of the diagnosis can be obtained by color Doppler ultrasound and surgery is the definitive means of treatment. < Testicular torsion (Choice D) Varicocele is a dilated spermatic vein that can be asymptomatic or present with dull scrotal aching worsened with standing and relieved with sitting. This patient's acute pain makes this diagnosis less likely. (Choice E) Viral orchitis without epididymitis (e.g., mumps, rubella, and parvovirus) can present with scrotal swelling, pain, and tenderness with erythema. However, it is more common in children and adolescents. Adults tend to present more commonly with epididymo-orchitis. Educational objective: Epididymitis usually presents with acute scrotal pain, exquisite testicular tenderness, and an intact cremasteric reflex. Diagnosis is usually made clinically, but Doppler ultrasound can be used in equivocal cases to document increased flow to the affected epididymis. Treatment usually consists of testicular elevation, NSAIDs, and antibiotics with close follow-up. __________ References: Diagnosis and management of epididymitis. (http://www.ncbi.nlm.nih.gov/pubmed/18061028) Epididymitis and orchitis: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/19378875)

A 43-Year-Old Man Seeks Care for a Painful Testicle