An 18-year-old man comes to the office due to 3 days of progressive left testicular pain. The pain began gradually and is dull and achy. The patient has had no trauma to that area and has never had similar symptoms. He has no fever, chills, urinary frequency, dysuria, urethral discharge, or penile ulcerations. The patient is sexually active. Vital signs are normal. The left testicle is lower in the scrotum than the right. The area posterior to the left testis is swollen and very tender. The pain improves with elevation of the testis, and the cremasteric reflex is normal. Urinalysis shows 4-5 white blood cells/hpf. Which of the following is the best next step in management of this patient?

Question

An 18-year-old man comes to the office due to 3 days of progressive left testicular pain.  The pain began gradually and is dull and achy.  The patient has had no trauma to that area and has never had similar symptoms.  He has no fever, chills, urinary frequency, dysuria, urethral discharge, or penile ulcerations.  The patient is sexually active.  Vital signs are normal.  The left testicle is lower in the scrotum than the right.  The area posterior to the left testis is swollen and very tender.  The pain improves with elevation of the testis, and the cremasteric reflex is normal.  Urinalysis shows 4-5 white blood cells/hpf.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d866_b7af_bc81_e3ca4921d8f7_MD0003_00 This patient with posterior testicular pain and swelling likely has acute epididymitis. Most cases arise when pathogens from the urethra travel in a retrograde fashion through the ejaculatory duct to the ductus deferens and epididymis. The likely underlying pathogen differs based on the age of the patient: Age <35: Most cases are caused by sexually transmitted infections, particularly Neisseria gonorrhoeae or Chlamydia trachomatis. Patients often have minimal urinary symptoms (eg, dysuria, frequency, urethral discharge) and mild or no pyuria. Age >35: Most cases are associated with bladder outlet obstruction (eg, benign prostatic hypertrophy) and are caused by coliform bacteria (eg, Escherichia coli). Patients generally have urinary symptoms and significant pyuria (eg. >25 leukocytes/hpf) on urinalysis. Epididymitis is often suspected when physical examination reveals posterior testicular swelling and tenderness that improves with elevation of the testes (Prehn sign). Confirmation requires urinalysis/urine culture and nucleic acid amplification testing for N gonorrhoeae and C trachomatis. Treatment with ceftriaxone plus doxycycline (for N gonorrhoeae or C trachomatis) or levofloxacin alone (for enteric pathogens) is generally curative. Nonsteroidal anti-inflammatory drugs and testicular elevation may provide symptomatic relief but must be accompanied by antibiotic therapy (Choice A). (Choice C) Urgent surgery is required for testicular torsion, which is usually characterized by severe testicular pain and a negative cremasteric reflex (ie, testes do not elevate with stroking of inner thigh). Most cases improve with detorsion and do not require orchiectomy. In addition, this patient's progressive pain over days, posterior testicular tenderness, and normal cremasteric reflex make torsion unlikely. (Choice D) Incision and drainage is occasionally required to treat hydrocele, a collection of fluid between the parietal and visceral layers of the tunica vaginalis; hydrocele is generally marked by painless testicular swelling over weeks or months. Incision and drainage may also be required for a testicular abscess, which is usually marked by a fluctuant fluid collection; pain from an abscess is unlikely to improve with elevation of the testes. hydrocele (Choice E) Renal and bladder ultrasound can identify urinary tract obstruction (eg, hydroureter) or certain renal pathologies (eg, cysts, neoplasm). It does not adequately visualize testicular conditions. Educational objective: Acute epididymitis is associated with posterior testicular pain/swelling, improvement of pain with testicular elevation, and normal cremasteric reflex. Most cases are caused by sexually transmitted pathogens (eg, Chlamydia, Neisseria) in patients age <35 and by colonic pathogens (eg, Escherichia coli) in those age >35. Treatment with antibiotics is required.

An 18-Year-Old Man Comes to the Office Due to 3