A 63-year-old man comes to the office due to 2 days of increasing scrotal pain. The pain is worse with touch or movement and is not relieved by over-the-counter ibuprofen. The patient also has mild burning on urination and increased urinary frequency. He has a history of hypertension, erectile dysfunction, and type 2 diabetes mellitus. He takes tadalafil but no other medications. The patient is married and sexually active with his wife. He does not use tobacco or alcohol. Temperature is 38.1 C (100.8 F), blood pressure is 130/75 mm Hg, and pulse is 86/min. Physical examination shows a tender mass in the left scrotum that is mildly erythematous. Cremasteric reflex is intact. No urethral discharge is present. Which of the following is the most likely cause of this patient's current condition?

Question

A 63-year-old man comes to the office due to 2 days of increasing scrotal pain.  The pain is worse with touch or movement and is not relieved by over-the-counter ibuprofen.  The patient also has mild burning on urination and increased urinary frequency.  He has a history of hypertension, erectile dysfunction, and type 2 diabetes mellitus.  He takes tadalafil but no other medications.  The patient is married and sexually active with his wife.  He does not use tobacco or alcohol.  Temperature is 38.1 C (100.8 F), blood pressure is 130/75 mm Hg, and pulse is 86/min.  Physical examination shows a tender mass in the left scrotum that is mildly erythematous.  Cremasteric reflex is intact.  No urethral discharge is present.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d27b_5eb5_bc81_bd08cf586478_MD0003_00 Acute epididymitis usually manifests with unilateral testicular pain and palpable swelling of the epididymis. The likely causative organism can often be predicted based on the age of the patient. Those age >35 most commonly develop epididymitis from bacteruria related to bladder outlet obstruction (eg, benign prostate hyperplasia). Ascending coliform bacteria such as Escherichia coli are the most likely pathogens, and urinary tract inflammatory symptoms (eg, dysuria, frequency) are common. epididymis Patients age <35 usually develop epididymitis due to sexually transmitted infections with Chlamydia trachomatis (Choice A) or Neisseria gonorrhoeae (Choice D). These organisms often cause asymptomatic urethritis, so urinary symptoms occur less frequently. Although patients of any age may engage in high-risk sexual behavior, this married 63-year-old man is far more likely to have a coliform bacterial infection than a sexually transmitted one. (Choice C) Mumps virus usually causes a nonspecific prodrome (fever, malaise, myalgias) followed by parotitis. The most common complication is epididymo-orchitis, which is typically characterized by high fever and severe testicular pain. This patient did not have prodromal or parotid symptoms, making this diagnosis far less likely. (Choice E) Staphylococcus aureus can cause epididymitis or orchitis in the setting of a surgical procedure or severe overlying skin infection but is otherwise unlikely. Educational objective: Acute epididymitis typically manifests with unilateral testicular pain and epididymal swelling. Those age >35 usually develop epididymitis due to bacteruria from bladder outlet obstruction; ascending coliform organisms such as Escherichia coli are the most likely pathogens. Patients age <35 are far more likely to have epididymitis due to sexually transmitted infections with Chlamydia trachomatis or Neisseria gonorrhoeae.

A 63-Year-Old Man Comes to the Office Due to 2