A 19-year-old male college student returns from spring break in Fort Lauderdale, Florida, with complaints of acute pain and swelling of the scrotum. Physical examination reveals an exquisitely tender, swollen right testis that is rather hard to examine. The cremasteric reflex is absent, but there is no swelling in the inguinal area. The rest of his genitourinary examination appears to be normal. A urine dip is negative for red and white blood cells. Which of the following is the appropriate next step in management?
The patient in the question may have a torsion of his testis that requires immediate attention. Another possibility would be epididymitis, especially if there is a possible antecedent history of sexual activity or urinary tract infection. Prehn sign, although not totally reliable, is elicited by gently lifting the scrotum toward the symphysis. Relief of the pain points to epididymitis; its worsening, to torsion. Doppler ultrasound (or surgical consultation) is a logical first step in this man's evaluation, demonstrating absence of flow in torsion and increased flow in epididymitis. Alternatively, a radionuclide scan will show diminished uptake in torsion and increased uptake in epididymitis.Treatment for torsion is surgical exploration and detorsion and scrotal orchiopexy. Causative organisms for epididymitis include Neisseria gonorrhoeae, C trachomatis, and other bacteria. Treatment with appropriate antibiotics and rest is indicated. However, treating this patient with antibiotics without first excluding testicular torsion is ill-advised; loss of the testis can be expected after 4 to 6 hours of absent blood flow if the testis has torsioned. Strangulated hernia is associated with evidence of intestinal obstruction.
Administration of antibiotics after culture of urethra for Chlamydia and gonorrhea
Reassurance
Intravenous fluid administration, pain medications, and straining of all voids
Ultrasound of the scrotum
Adolescence