Case Study Helen McDonald

CC: “Testicle swelling” HPI: 30 year old male presents to PCP with 4 day history of worsening right testicle swelling, redness and pain 8/10, sharp/aching, increases with movement or sitting, improves with elevation, laying down, denies OTC meds, Temp 101.0, chills, burning with urination, frequency, Denies trauma, penile discharge, erectile dysfunction, one monogamous sexual partner for 5 years, works in lumber yard requiring heavy lifting

Family Hx: Denies family hx lung diseases, Stroke, cancer PMH: Denies PSH: Appendectomy 2012 Meds: Denies Immunization: MMR, IPV, DTap with booster 2013, HEP B Series, influenza vaccine fall 2015, denies Pneumonia vaccine, PPD Allergies: No known food/drug/dye/latex Social Hx: Resides with S.O. of 5 yrs, no children, works at a lumber yard requiring heavy lifting, uses proper lifting techniques, forklift operator, wears safety equipment, smokes 1ppd, drinks ETOH socially, denies illicit drug use Family Hx: Denies family hx lung diseases, Stroke, cancer Father 55 DM, Mother 53 AW, PGF 77 DM, PGM 77 HTN, MGF 62 Deceased MI, MGM 75 HTN, Brother 33 AW, Sister 35 AW

ROS General: Reports fever 101.0, chills, Denies malaise, night sweats, changes in appetite Respiratory: Denies Pain, dyspnea, orthopnea, wheezing, cough, sputum Cardiac: Denies high blood pressure, heart murmurs, pain, palpitations, dyspnea Gastrointestinal: BM once daily, brown, soft, Denies constipation, diarrhea, flatulence, hemorrhoids, blood in stools, rectal bleeding

ROS Continued Urinary: As per HPI, Denies hematuria, urgency, reduced force of stream, hesitancy, dribbling, incontinence, infections, stones, pain Genital: As per HPI, One sexual partner for 5 years, Denies use of protection, history of STD, hernias, testicular self-exam in the shower Skin: Reports redness right scrotal area, denies rash, eruption, itching, texture changes

Physical Exam General Appearance: Well developed, well-nourished 30 year old male, alert, oriented, cooperative, no distress Vital Signs: T: 100.2 P: 78 R: 29 BP (sitting): 110/70 Ht: 5’10” Wt: 230lbs BMI: 33 Chest/Lungs: Breath sounds bilaterally clear CV/PV: Regular rate rhythm, S1 & S2 intact no murmurs, gallops, thrills, clicks, rub

Physical Exam Cont. Abdomen: Symmetrical, no scars, lesions, bowel sounds present four quadrants, medium pitch every 15 seconds, tympany, no guarding, pain, organomegaly, masses Male Genital: Circumcised, no urethral discharge, hernia exam negative, no masses, testicles descended, Right epididymis thickened and tender Skin: Right scrotum induration, erythema

Diagnostic UA – Positive for UTI

What’s the diagnosis?

Differential Diagnosis ICD10-D Testicular Torsion ICD10-D Orchitis ICD20-D Epididymitis ICD10-D Testicular Malignancy ICD10-D Epididymal Cyst ICD10-D Inguinal Hernia ICD10-D Hydrocele ICD10-D Spermatocele ICD10-D Varicocele

Chronic vs Acute Infectious vs Sterile Epididymitis Chronic vs Acute Infectious vs Sterile

Anatomy

Prevalence Young, sexually active men Older men with bladder outlet obstruction BPH

Risk Factors UTI Prostatitis Indwelling Foley Cath Urethral stricture Anal intercourse High-risk sexual activity Foreskin Constipation HIV immunosuppression Urethral or transrectal procedures Prolonged sedentary periods Strenuous physical activity

Etiology <35 years old >35 years old Sexually active Serous urethral discharge - Chlamydia trachomatis Purulent discharge - Neisseria gonorrhoea Anal intercourse – E. coli >35 years old Coliform bacteria Staphylococcus aureus S. epidermidis BPH, UTI, Catheter

Clinical Findings Scrotal pain, possibly radiating to groin Elevation of testes improves pain (Prehn sign) Urethral discharge UTI symptoms Epididymis tail larger than counterlateral side Hemiscrotal swelling, induration, wall thickening Cremasteric reflex (Inner thigh stroke) present in epididymitis if absent testicular torsion maybe the cause

Diagnosis Clinical diagnosis Other suggestions Urine Culture Chlamydia testing WBC Doppler Ultrasound

Ultrasound

Antibiotics 1st line PCN allergy or anal intercourse 2nd line Chlamydia: Doxycycline 100mg PO BID x10days Ceftriaxone 250mg IM x 1 dose PCN allergy or anal intercourse Cipro 500mg PO BID x 10 days Floxin 200mg PO BID x 10 days 2nd line Bactrim DS PO BID 10-14 days Analgesia NSAID

ABX for older men with bacteriuria Levaquin 500mg PO QD 7-10 days Cipro 500mg PO BID 10-14 days

Education Bed rest Activity restriction Athletic scrotal support Scrotal elevation Ice and warm compresses Safe sex practices Treating partners for chlamydia

Follow Up Every couple of days in office until resolved

Questions

References Domino, F. J., Baldor, R. A., Golding, J., Grimes, J. A., & Taylor, J. S. (2013). The 5-minute clinical consult 2013. Philladelphia, PA: Lipplincott UpToDate. (2015). Evaluation of the acute scrotum in adults. Retrieved from http://www.uptodate.com/contents/evaluation of-the-acute-scrotum-in adults?source=machineLearning&search=epid dymitis&selectedTitle=1~80&sectionRank=2 anchor=H26#H26