NU-623 Herzing University – You are seeing a 22-year-old male patient at the college student health clinic. His chief complaint is scrotal pain and swelling

QUESTION

You are seeing a 22-year-old male patient at the college student health clinic. His chief complaint is scrotal pain and swelling. He has had some frequency of urination and purulent penile discharge, but no fever. He admits to being sexually active, with his new girlfriend of two weeks. He has tried Tylenol and ibuprofen at home and nothing helps.

1). As you enter the treatment room, the patient appears anxious and uncomfortable. What additional history should you obtain from the patient?

2). What physical examination components are indicated for this presentation?

3). Based on the presentation and history, you recognize the need to screen for sexually transmitted infections (STIs).  What are the most common STIs for this presentation?

4). After your assessment, all subjective and objective findings should be considered when developing differential diagnoses for scrotal pain and swelling with accompanying urinary complaints. What may be included on a differential list?

5). Name your priority diagnosis and provide the treatment plan. If you elect to treat with medications, provide full prescription details and follow up plan.

6). As the practitioner, you are required to report certain STIs to your state health department. Provide a list of the STI’s that must reported in your state along with the information that needs to be included when reporting these.

ANSWER

Scrotal Pain and Swelling with Urinary Complaints: Assessment and Management

Introduction

Scrotal pain and swelling accompanied by urinary complaints can be a distressing condition for patients, particularly in young adults who are sexually active. This essay aims to provide a comprehensive approach to the evaluation and management of a 22-year-old male patient presenting with scrotal pain and swelling, along with urinary symptoms. We will explore the essential components of history taking and physical examination, discuss common sexually transmitted infections (STIs) associated with this presentation, consider the differential diagnoses, propose a priority diagnosis, and outline an appropriate treatment plan. Additionally, we will address the reporting requirements for STIs to the state health department.

Obtaining Additional History

Upon entering the treatment room, it is crucial to establish a rapport with the patient, who may appear anxious and uncomfortable. In addition to a standard medical history, obtaining specific information is vital: a) Sexual History: A detailed sexual history should be taken, including the number of sexual partners, the type of sexual activity engaged in, and the use of protection. This information helps determine the risk of acquiring STIs. b) Symptoms: Inquire about the onset, duration, and severity of scrotal pain and swelling, along with urinary symptoms such as dysuria and hematuria (The Initial Reproductive Health Visit, n.d.). Any history of previous STIs or recent exposure should also be explored.

Physical Examination Components

To further evaluate the patient’s condition, several physical examination components are indicated: a) Scrotal Examination: Inspect and palpate the scrotum for swelling, tenderness, or masses. This assessment aids in diagnosing epididymitis, testicular torsion, or other scrotal pathologies. b) Penile Examination: Examine the penis for signs of inflammation, lesions, or discharge, which can help identify urethritis or STIs. c) Inguinal Lymph Nodes: Assess the inguinal lymph nodes for enlargement or tenderness, as lymphadenopathy may be present in certain STIs. d) Abdominal Examination: Perform an abdominal examination to identify any signs of tenderness or masses that could be related to underlying conditions.

Common STIs for this Presentation

Based on the symptoms and history provided, the most common STIs to consider include: a) Gonorrhea: Symptoms may include purulent penile discharge and urinary frequency. b) Chlamydia: Symptoms may include urinary frequency, urethral discharge, and testicular pain. c) Epididymitis: Inflammation of the epididymis can cause scrotal pain and swelling, often associated with urinary symptoms.

Differential Diagnoses

When developing a differential diagnosis for scrotal pain and swelling with urinary complaints, several conditions should be considered: a) Epididymitis or Epididymo-orchitis: Inflammation of the epididymis or epididymis and testicle. b) Testicular Torsion: Twisting of the testicle, which is a surgical emergency. c) Urethritis: Inflammation of the urethra, often caused by infectious agents. d) Urinary Tract Infection: Infection involving the urinary system, which may cause urinary symptoms and scrotal discomfort. e) STIs: Other STIs such as syphilis or herpes simplex virus can also present with similar symptoms. f) Inguinal Hernia: A protrusion of abdominal contents through the inguinal canal. g) Trauma or Injury: Recent trauma or injury to the scrotum or genital area.

Priority Diagnosis and Treatment Plan

Considering the patient’s symptoms and the likelihood of an STI, the priority diagnosis is epididymitis or epididymo-orchitis, possibly due to a sexually transmitted infection. The following treatment plan is recommended: a) Antibiotic Therapy: Prescribe broad-spectrum antibiotics such as ceftriaxone (for possible gonorrhea) and doxycycline or azithromycin (for possible chlamydia) to target common pathogens. Dosage and duration of treatment should follow local guidelines and antibiotic resistance patterns. b) Analgesics: Recommend nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen to alleviate pain and inflammation. c) Bed Rest and Scrotal Elevation: Advise the patient to rest and elevate the scrotum to reduce swelling and discomfort. d) Sexual Partner Notification and Testing: Emphasize the importance of informing the patient’s new girlfriend about the situation and encourage her to seek medical evaluation and testing for STIs (Nicholson et al., 2010). e) Follow-up: Schedule a follow-up appointment to assess treatment response, monitor for complications, and ensure resolution of symptoms.

Reporting Requirements for STIs to the State Health Department

Reporting requirements for STIs vary by state. However, commonly reportable STIs may include gonorrhea, chlamydia, syphilis, HIV/AIDS, and hepatitis B and C. The state health department typically requires the following information for reporting: a) Patient Demographics: Name, age, address, and contact information of the patient. b) Type of STI Diagnosed: Specify the diagnosed STI. c) Date of Diagnosis: Provide the date when the diagnosis was made. d) Laboratory Confirmation: Include details of laboratory confirmation, if available (Newman et al., 2009). e) Relevant Clinical Information: Describe any additional pertinent clinical information related to the case. f) Partner Notification and Treatment: Document information regarding partner notification and treatment, if applicable.

Conclusion

The evaluation and management of scrotal pain and swelling with urinary complaints in young male patients require a thorough history, comprehensive physical examination, consideration of common STIs, and formulation of an appropriate treatment plan. Prompt diagnosis, timely initiation of antibiotic therapy, and patient education regarding partner notification and safe sexual practices are essential for successful outcomes. Additionally, adherence to reporting requirements ensures the tracking and surveillance of STIs, aiding in public health efforts to prevent their spread.

References

Newman, L. R., Samuel, M. D., Stenger, M. R., Gerber, T., Macomber, K., Stover, J. A., & Wise, W. (2009). Practical Considerations for Matching STD and HIV Surveillance Data with Data from other Sources. Public Health Reports, 124(2_suppl), 7–17. https://doi.org/10.1177/00333549091240s203 

Nicholson, A., Rait, G., Murray-Thomas, T., Hughes, G., Mercer, C. H., & Cassell, J. (2010). Management of epididymo-orchitis in primary care: results from a large UK primary care database. British Journal of General Practice, 60(579), e407–e422. https://doi.org/10.3399/bjgp10x532413 

The Initial Reproductive Health Visit. (n.d.). ACOG. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/10/the-initial-reproductive-health-visit