An 18-year-old man comes to the office due to 2 days of right testicular pain. The pain is constant and exacerbated by movement. Vital signs are within normal limits. On physical examination, there is swelling and tenderness to palpation localized only to the posterior and superior areas of the right testis. The left testis is normal. Cremasteric reflexes are intact bilaterally. Urinalysis shows numerous leukocytes but no bacteria. Which of the following factors most likely contributed to this patient's current condition?

Question

An 18-year-old man comes to the office due to 2 days of right testicular pain.  The pain is constant and exacerbated by movement.  Vital signs are within normal limits.  On physical examination, there is swelling and tenderness to palpation localized only to the posterior and superior areas of the right testis.  The left testis is normal.  Cremasteric reflexes are intact bilaterally.  Urinalysis shows numerous leukocytes but no bacteria.  Which of the following factors most likely contributed to this patient's current condition?

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11ec160b_399f_ae17_9249_c90f5aef6976_MD0001_00 This patient's acute testicular pain, posterior testicle tenderness, and pyuria raises suspicion for acute epididymitis. Most cases occur when genitourinary pathogens travel in a retrograde fashion from the urethra via the ejaculatory duct to the vas deferens. The most likely underlying organism can often be inferred based upon the age of the patient: Young men (age <35) usually develop acute epididymitis due to Chlamydia trachomatis or Neisseria gonorrhoeae, sexually transmitted pathogens acquired during unprotected sexual intercourse. Although these organisms often cause asymptomatic urethritis (no dysuria), pyuria is typically seen on urinalysis. Nucleic acid amplification testing is required for diagnosis because urine culture is generally negative. Older men (age >35) are less likely to have sexually transmitted infections due to fewer sexual partners and increased rates of monogamy. Acute epididymitis in these patients is generally due to gram-negative colonic flora (eg, Escherichia coli), which contaminate the urethra, ascend into the urinary system, and subsequently invade the ejaculatory duct and vas deferens. Most cases arise in the setting of urethral obstruction (eg, benign prostatic hypertrophy) and are characterized by urinary tract symptoms (eg, dysuria, urinary frequency), bacteruria on urinalysis, and positive urine culture (Choice E). (Choice A) Mumps can occur in those who did not receive appropriate childhood vaccinations and usually presents with a nonspecific prodrome (fever, malaise, myalgias) followed by parotitis. Complications include orchitis, with high fever and severe diffuse testicular pain, which are not seen in this patient. (Choice B) Varicocele is characterized by distension of the pampiniform plexus due to elevated gonadal venous pressure. It presents as a soft scrotal mass that feels like a "bag of worms" on palpation. Pain is mild or absent. (Choice C) Testicular torsion is the result of inadequate fixation of the lower pole of the testis to the tunica vaginalis. It is usually characterized by sudden-onset, severe, unilateral testicular pain; nausea; a high-riding testis; and loss of the cremasteric reflex (elevation of testis on pinching of the skin at the upper thigh). Educational objective: Epididymitis presents with acute testicular pain, tenderness, and pyuria. It is caused by retrograde passage of organisms from the urethra into the ejaculatory duct and vas deferens. The microbiology is largely influenced by patient age: epididymitis in young men is usually due to sexually acquired infections (eg, Chlamydia trachomatis, Neisseria gonorrhoeae), whereas in older men (age >35) it is usually due to gram-negative colonic flora. __________ References: Epididymitis: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/27929243)

An 18-Year-Old Man Comes to the Office Due to 2