A 27-year-old man presents with 3 days of gradually worsening left testicular pain and swelling. He reports dysuria and urinary frequency but denies trauma, nausea, or vomiting. During a private sexual history, he reports a new sexual partner and inconsistent condom use. Examination reveals mild left scrotal swelling and tenderness greatest over the epididymis. Both testes have a normal vertical lie, and the cremasteric reflex is present bilaterally. There is no blue dot sign or inguinal mass. Urinalysis demonstrates leukocyte esterase and pyuria.
Which of the following is the most appropriate next step?
- Obtain gonorrhea and chlamydia testing and treat empirically for likely infectious epididymo-orchitis
- Immediate transfer for surgical exploration for presumed testicular torsion
- Provide reassurance and NSAIDs without additional testing
- Arrange urgent urologic referral for suspected testicular cancer
Click to see the answer
Correct answer: a. Obtain gonorrhea and chlamydia testing and treat empirically for likely infectious epididymo-orchitis.
Rationale: The gradual onset of pain, epididymal tenderness, urinary symptoms, pyuria, and sexual exposure favor epididymo-orchitis. Sexually active patients should be tested for gonorrhea and chlamydia, and empiric antimicrobial therapy should be selected according to the most likely pathogens and sexual practices.
For an in-depth review of this topic, access the full course.
Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
