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Peer Responses:
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Relate to another journal reading
A 32-year-old male arrives to the clinic complaining of acute onset testicular pain for the past 2 days.
Pertinent questions to ask this patient are as follows:
When did the pain begin?
Where is the pain specifically?
Does the pain radiate anywhere?
How long has the pain lasted?
Can you describe the type of pain you are experiencing?
What aggravates the pain?
Is there anything that relieves the pain?
When does the pain occur?
Can you rate the pain 0-10 on the pain scale?
Are you currently sexually active?
Have you engaged in unprotected sex recently?
Has this happened to you in the past?
Have you experienced any recent scrotal trauma?
Do you sit or ride a bicycle for long periods?
Have you experienced any penile discharge?
Do you have burning on urination, frequency, or urgency?
Have you recently lifted any heavy objects?
The physical examination is an important aspect of arriving at a diagnosis and will begin with observation to assess positioning of the testes to determine if there is edema, erythema, induration, hard lump, engorged veins, and scrotal transillumination. The patient will be assessed for cremasteric reflex, bell clapper deformity, and unilateral elevation of the testes. Of importance is assessing for a palpable lump at the superior pole of the testis that appears like a blue dot (Dunphy et al., 2023). Palpation can also confirm the feeling of a “bag of worms” in the scrotal sac indicative of blood vessel engorgement. Following a thorough history and physical the following differentials are considered in this case. Differential Diagnosis
Epididymitis Scrotal pain is often the chief complaint for the individual with epididymitis. This condition results from an inflammation of the epididymis, the coiled apparatus that connects the rete testis to the vas deferens allowing for sperm maturation (Dunphy et al., 2023). The inflammation can result from a variety of reasons including urinary tract infection, heavy lifting, sexually transmitted infection, bacterial infection, and intravesical therapy for cancer (Dunphy et al., 2023). Those individuals with prostatitis, urinary tract infection, urethral stricture, or recent prostate surgery are particularly at risk for epididymitis (Dunphy et al., 2023). Non-bacterial origin for epididymitis can be because of urinary retrograde extravasation. Diagnostic Plan
Diagnosis involves a thorough history and physical examination including elevation of the testes to determine if pain is relieved, a pertinent positive for epididymitis known as Prehn’s sign (Dunphy et al., 2023). Subjective findings in acute epididymitis includes radiating pain from the scrotum to the flank, penile tip pain, urethral discharge, dysuria, frequency, and pan at the lower section of the posterior lying epididymis (Dunphy et al., 2023). Objective findings include swelling of the scrotum, scrotal thickening and induration, and prostate tenderness during rectal examination (Dunphy et al., 2023). Urinalysis serves to determine the presence of bacteria, and cultures/gram staining to determine the presence of gonorrhea or chlamydia. A complete blood count with a left shift can indicate the presence of a bacterial origin. Testicular ultrasound is confirmative for epididymitis. Testicular Torsion
Known as a urological emergency, testicular torsion is an ischemic event of the testes resulting from twisting or rotation of the testes (Dunphy et al., 2023). In untreated cases of torsion, infertility and testicular loss can occur. Testicular torsion can result from a cryptorchid testicle that fails to descend into the scrotal sac. Although testicular torsion can occur at any age, it is more prevalent in younger males between 10-20 years of age (Dunphy et al., 2023). Often testicular torsion is an acute idiopathic event with trauma history in about 20% of cases (Dunphy et al., 2023). It is also more prevalent in runners and those who ride bicycles for long periods (Dunphy et al., 2023). One defining sign is the presence of cremaster muscle contraction that tends to occur during sleeping in 50% of males. Other contributing factors are recent exposure to cold weather, sitting for longer periods, varying testosterone levels, congenital anomalies, and cremasteric contractions during sexual activity (Dunphy et al., 2023). Diagnostic Plan Acute testicular pain and swelling are generally the chief complaint in testicular torsion. A complete history and physical is necessary to determine the presence of contributing factors as aforementioned. The physical examination focuses on determining if the cremasteric is absent indicating the strong possibility of torsion. Other findings include a high riding testicle with a “bell clapper” alteration (Dunphy et al., 2023). In the case of torsion, elevation of the testes does not provide pain relief as it does in the case of epididymis. Another definitive sign is the blue dot sign, which is elicited by pulling the skin taut over a palpable lump in the appendix testis indicating the presence of necrosis (Dunphy et al., 2023). Ultrasonography using color doppler within 12 hours of the event and radionuclide scanning to assess vascularity can be utilized to diagnose a testicular torsion (Dunphy et al., 2023). Varicocele
The abnormal venous dilation of the pampiniform plexus within the spermatic vein occurs in the condition known as a varicocele. This results from weakness of the spermatic cord wall prompting vascular engorgement and can also occur from pressure on these structures (Dunphy et al., 2023). Usually, a varicocele is found on the left testicle, but can be bilateral. Because the left spermatic vein is the longest vein within the body, it is under higher amounts of pressure in respect to its location and is more prone to back pressure from retrograde flow of blood resulting in a varicocele (Dunphy et al., 2023). Diagnostic Plan
Presenting symptoms relating to a varicocele are often associated with pain and the scrotal sac feeling like a “bag of worms” (Dunphy et al., 2023). Generally, patients are referred to urology to rule out complications of a more serious nature. During the physical exam, the provider can assess the veins tortuous path superior to the testis and may extend further to the inguinal ring (Dunphy et al., 2023). Having the patient mimic a Valsalva maneuver when in a recumbent position elicits a vasodilatory effect, and then the opposite will occur in the absence of bearing down, this is known as a Grade I varicocele (Dunphy et al., 2023). A grade 2 is felt when standing, and a grade 3 is both palpable and visualized on examination. Of importance is assessing the sperm count which is found to be low in the case of a varicocele (Dunphy et al., 2023). Other confirmatory diagnostic tests utilized to visualize the vascularity and to assess temperature include a venography, scrotal ultrasound, and thermography. A surgical consult may be warranted to ligate the spermatic vein to decompress the varicocele (Dunphy et al., 2023). Lead Diagnosis: Epididymitis Treatment Plan:
The treatment plan for epididymitis begins with urethral secretion gram staining testing for sexually transmitted infections in men presenting with acute symptoms who are sexually active. A urinalysis is obtained to assess for presence of WBC and can be used for testing for sexually transmitted infections, namely chlamydia and gonorrhea (CDC, 2021). The initial treatment plan will be guided by culture and sensitivity reports and may include antibiotics such as Rocephin 500mg IM for 1 dose with Doxycycline 100mg orally twice daily for 10 days in the case of confirmed gonorrhea and chlamydia (CDC, 2021). If positive for chlamydia and/or gonorrhea and engaging in anal sex the treatment plan is Rocephin 500mg IM X 1 dose with Levaquin 500mg orally daily for 10 days and Levaquin 500mg orally daily for 10 days for enteric infections (CDC, 2021). Studies show that treatment of epididymitis with the aforementioned regimen is efficacious for antimicrobial etiologies of epididymitis (Louette et al., 2018). Other treatment recommendations include bedrest, scrotal elevation, and fever control with use of NSAIDs (CDC, 2021). If confirmed positive for gonorrhea and chlamydia, clinical guidelines suggest treating sexual partners and abstaining from sexual activity until symptoms resolve and treatment concludes (Louette et al., 2018). Follow up is encouraged if symptoms do not show improvement in 72 hours and resolution of epididymitis symptoms in 3 days (CDC, 2021). In case of incomplete symptom resolution following treatment, evaluation for other pathology including tumors, cancer, and fungal infection (CDC, 2021). Conclusion
Prompt assessment and treatment of epididymitis is integral to assuring better patient outcomes. Any delay in the appropriate treatment plan for epididymitis can result in infertility, abscess formation, and Fournier’s gangrene warranting patient education of the importance of completing the prescribed therapy (Dunphy et al., 2023). Patients are also educated to monitor self-symptoms and to follow up promptly if the symptoms persist following the course of therapy.
References
Centers for Disease Control (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. Epididymitis. Retrieved from: https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2023). Primary Care: The Art and Science of Advanced Practice Nursing – and Interprofessional Approach (6th ed.). F. A. Davis Company. ISBN 1719644659
Louette, Aaron*; Krahn, Jessica*; Caine, Vera PhD*; Ha, Shalane MSc†; Lau, Tim T. Y. PharmD‡; Singh, Ameeta E. BMBS, MSc§. Treatment of Acute Epididymitis: A Systematic Review and Discussion of the Implications for Treatment Based on Etiology. Sexually Transmitted Diseases 45(12):p e104-e108, December 2018. | DOI: 10.1097/OLQ.0000000000000901