A 24-year-old man comes to the office following 1-2 days of worsening right scrotal pain. He has had no trauma, fever, chills, dysuria, or urethral discharge. The patient has no history of similar symptoms or prior medical conditions and takes no medications. He has been sexually active with a female partner over the past several months; she takes an oral contraceptive for birth control. The patient drinks 1 or 2 cans of beer daily and occasionally smokes marijuana, but he does not use tobacco or intravenous drugs. Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 14/min. Examination of the external genitalia shows no penile ulcers or lesions. There is mild, right-sided scrotal erythema, swelling, and tenderness. Light stroking of the upper-inner thigh elicits normal cremaster muscle contraction on both sides. There are no enlarged inguinal lymph nodes. The patient inquires about the next course of action. Which of the following is the most appropriate response to this patient?

Question

A 24-year-old man comes to the office following 1-2 days of worsening right scrotal pain.  He has had no trauma, fever, chills, dysuria, or urethral discharge.  The patient has no history of similar symptoms or prior medical conditions and takes no medications.  He has been sexually active with a female partner over the past several months; she takes an oral contraceptive for birth control.  The patient drinks 1 or 2 cans of beer daily and occasionally smokes marijuana, but he does not use tobacco or intravenous drugs.  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 80/min, and respirations are 14/min. Examination of the external genitalia shows no penile ulcers or lesions.  There is mild, right-sided scrotal erythema, swelling, and tenderness.  Light stroking of the upper-inner thigh elicits normal cremaster muscle contraction on both sides.  There are no enlarged inguinal lymph nodes.  The patient inquires about the next course of action.  Which of the following is the most appropriate response to this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c17f_c785_8f63_cdd3ff67b4d4_MD0005_00 This patient has a typical presentation of acute epididymitis, with acute, progressive scrotal pain accompanied by swelling and tenderness. Epididymitis in young men (age <35) is typically due to sexually transmitted organisms (eg, Neisseria gonorrhoeae, Chlamydia trachomatis) and may be associated with urethritis (eg, urethral discharge, pain at the tip of the penis). Epididymitis in older men is usually due to nonsexually transmitted coliform bacteria (eg, Escherichia coli). The initial evaluation of epididymitis should include urinalysis and culture. Nucleic acid amplification testing for N gonorrhoeae and C trachomatis is also indicated and can quickly identify these organisms. The choice of initial antibiotic therapy is dependent on the likely pathogen. If gonorrhea cannot be ruled out (eg, acute urethritis or proctitis, high risk of sexually transmitted infections), the patient should receive ceftriaxone plus doxycycline. Fluoroquinolones (eg, levofloxacin) are appropriate for patients with low risk of gonococcal infection but should not be used if gonorrhea is a possibility due to increasing antibiotic resistance. (Choice B) Comfort measures for acute epididymitis include scrotal elevation and nonsteroidal anti-inflammatory drugs (eg, ibuprofen). However, empiric antibiotic therapy should also be given based on the most likely pathogens. (Choice C) Urgent urologic evaluation is indicated for testicular torsion. Torsion typically presents with acute, severe pain associated with a high-riding, rotated testis (bell-clapper deformity) and loss of the cremasteric reflex. This patient's clinical findings are more consistent with epididymitis. (Choice D) Viral orchitis (eg, mumps, rubella, parvovirus) can present with scrotal swelling, pain, tenderness, and erythema. However, it is more common in children and adolescents, and extraurinary manifestations are common. extraurinary manifestations (Choice E) Testicular needle aspiration/biopsy is useful in the evaluation of nonobstructive azoospermia, masses, and testicular cysts. This patient has no palpable masses, and his acute symptoms are more consistent with epididymitis. Educational objective: Epididymitis is characterized by scrotal pain, swelling, and tenderness. The initial evaluation should include urinalysis and culture. Nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis can quickly identify these organisms. Empiric antibiotic therapy is chosen based on the likely pathogen. References: Epididymitis and orchitis: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/19378875)

A 24-Year-Old Man Comes to the Office Following 1-2 Days