Case Study

Helen McDonald

CC: Testicle swelling

O 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

O PMH: Denies
O PSH: Appendectomy 2012
O Meds: Denies
O Immunization: MMR, IPV, DTap with booster 2013, HEP B

Series, influenza vaccine fall 2015, denies Pneumonia vaccine,

PPD
O Allergies: No known food/drug/dye/latex
O 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
O Family Hx: Denies family hx lung diseases, Stroke, cancer
O 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
O General: Reports fever 101.0, chills, Denies

malaise, night sweats, changes in appetite

O Respiratory: Denies Pain, dyspnea,
orthopnea, wheezing, cough, sputum
O Cardiac: Denies high blood pressure, heart
murmurs, pain, palpitations, dyspnea
O Gastrointestinal: BM once daily, brown, soft,
Denies constipation, diarrhea, flatulence,
hemorrhoids, blood in stools, rectal bleeding

ROS Continued
O Urinary: As per HPI, Denies hematuria,

urgency, reduced force of stream, hesitancy,

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

Physical Exam
O General Appearance: Well developed, well-

nourished 30 year old male, alert, oriented,

cooperative, no distress
O Vital Signs: T: 100.2 P: 78 R: 29 BP
(sitting): 110/70 Ht: 510 Wt: 230lbs BMI:
33
O Chest/Lungs: Breath sounds bilaterally clear
O CV/PV: Regular rate rhythm, S1 & S2 intact
no murmurs, gallops, thrills, clicks, rub

Physical Exam Cont.

O Abdomen: Symmetrical, no scars, lesions, bowel

sounds present four quadrants, medium pitch every

15 seconds, tympany, no guarding, pain,
organomegaly, masses
O Male Genital: Circumcised, no urethral
discharge, hernia exam negative, no
masses, testicles descended, Right
epididymis thickened and tender
O Skin: Right scrotum induration, erythema

Diagnostic
O UA Positive for UTI

Whats the diagnosis?

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

Epididymitis
Chronic vs Acute
Infectious vs Sterile

Anatomy

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

Risk Factors
O UTI

O Foreskin

O Prostatitis

O Constipation

O Indwelling Foley

Cath
O Urethral stricture
O Anal intercourse
O High-risk sexual
activity

O HIV

immunosuppression
O Urethral or transrectal
procedures
O Prolonged sedentary
periods
O Strenuous physical
activity

Etiology
O <35 years old
O Sexually active
O Serous urethral

discharge - Chlamydia
trachomatis
O Purulent discharge Neisseria gonorrhoea
O Anal intercourse E.
coli

O >35 years old

O Coliform bacteria
O Staphylococcus

aureus
O S. epidermidis
O BPH, UTI,
Catheter

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

epididymitis if absent testicular torsion maybe

the cause

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

Ultrasound

Antibiotics
O 1st line
O Chlamydia:
O Doxycycline 100mg PO BID x10days
O Ceftriaxone 250mg IM x 1 dose

O PCN allergy or anal intercourse

O Cipro 500mg PO BID x 10 days
O Floxin 200mg PO BID x 10 days
O 2nd line
O Bactrim DS PO BID 10-14 days

O Analgesia
O NSAID

ABX for older men with

bacteriuria
O Levaquin 500mg PO QD 7-10 days
O Cipro 500mg PO BID 10-14 days

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

Follow Up
O Every couple of days in office until

resolved

Questions

References
O Domino, F. J., Baldor, R. A., Golding, J., Grimes, J. A.,
& Taylor, J. S. (2013). The 5-minute clinical
consult 2013. Philladelphia, PA: Lipplincott
O UpToDate. (2015). Evaluation of the acute
scrotum inadults. 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