A 27-year-old man comes to the emergency department due to scrotal pain. Three days ago, he was diagnosed with acute epididymitis by his primary care physician and was treated with ceftriaxone and doxycycline. Nuclear acid amplification test for Chlamydia trachomatis was positive. He has persistent pain and states that he has been compliant with his oral doxycycline. He denies anal intercourse.
Examination reveals tenderness and swelling involving the left side of the scrotal sac. The pain is relieved with elevation of the sac and the cremasteric reflex is equivocal. Rectal examination shows a normal-sized and nontender prostate.
Which of the following is the most appropriate next step in management?

Question

A 27-year-old man comes to the emergency department due to scrotal pain.  Three days ago, he was diagnosed with acute epididymitis by his primary care physician and was treated with ceftriaxone and doxycycline.  Nuclear acid amplification test for Chlamydia trachomatis was positive.  He has persistent pain and states that he has been compliant with his oral doxycycline.  He denies anal intercourse.
Examination reveals tenderness and swelling involving the left side of the scrotal sac.  The pain is relieved with elevation of the sac and the cremasteric reflex is equivocal.  Rectal examination shows a normal-sized and nontender prostate.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9651_e66b_853d_21ea88cf87a0_MD0002_00 This patient has refractory scrotal pain despite adequate therapy for epididymitis, and he should be evaluated for more emergent causes (eg, testicular torsion, testicular abscess, or testicular infarction). History and physical examination often cannot differentiate between these diagnoses. For instance, although an abscess usually demonstrates fluctuance, the examination may not always show this. Similarly, although testicular torsion (associated with an absent cremasteric reflex) is more common in boys age ≤12, it can also occur in adult men. testicular torsion Despite receiving antibiotic therapy, this patient has persistent left-sided scrotal pain and swelling that is decreased with sac elevation (consistent with but not specific to epididymitis, and uncommon in testicular torsion) along with an equivocal cremasteric reflex. He needs immediate evaluation by a urologist and ultrasonography or radionuclide scrotal imaging to identify the cause of his pain and to determine the need for surgical intervention. Although he was initially diagnosed with epididymitis, this particular patient was eventually found to have testicular cancer, which can occasionally present as acute testicular pain. (Choices A and B) Adding either drug would not address possible alternative emergency diagnoses. Changing antibiotics would likely not improve outcomes, as Chlamydia trachomatis has low levels of in vitro and in vivo resistance to quinolones, macrolides, and doxycycline. Addition of fluoroquinolones (eg, ofloxacin or levofloxacin) is recommended if the suspected cause of epididymitis is due to enteric organisms (eg, Escherichia coli). Epididymitis is usually seen in men age ≥35 and in men who engage in anal intercourse. (Choice C) Current guidelines recommend HIV and syphilis testing in men with high-risk behavior or with sexually transmitted infections. Although this patient has a sexually transmitted infection and may require HIV and syphilis testing, neither of these are likely to cause his current pain. (Choice D) Patients should note symptomatic improvement after 1-3 days of therapy for epididymitis. Patients without improvement should undergo investigation for complications or antibiotic resistance, instead of reassurance and analgesics. Educational objective: Patients with epididymitis refractory to therapy require investigation (eg, scrotal ultrasound) for emergent etiologies (eg, torsion) or complications (eg, abscess, infarction). __________ References: Role of color Doppler ultrasonography in evaluation of scrotal swellings: pattern of disease in 120 patients with review of literature (http://www.ncbi.nlm.nih.gov/pubmed/21404205) Epididymitis and orchitis: an overview (http://www.ncbi.nlm.nih.gov/pubmed/19378875)

A 27-Year-Old Man Comes to the Emergency Department Due to Scrotal