1. Case Study
Helen McDonald

2. 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

3. 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

4. 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

5. 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

6. Physical Exam
General Appearance: Well developed, well-nourished 30 year old male, alert, oriented, cooperative, no distress
Vital Signs: T: 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

7. 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

8. Diagnostic
UA – Positive for UTI

9. What’s the diagnosis?

10. 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

11. Chronic vs Acute Infectious vs Sterile
Epididymitis
Chronic vs Acute
Infectious vs Sterile

12. Anatomy

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

14. 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

15. 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

16. 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

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

18. Ultrasound

19. 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 days
Analgesia
NSAID

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

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

22. Follow Up
Every couple of days in office until resolved

23. Questions

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