Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor covering the emergency department. You are asked to see Edward Gupta, a 25-year-old professional tennis player, complaining of scrotal swelling. Please take a history and perform a relevant examination.
Patient History:
Edward Gupta - a 25-year-old male - professional tennis player.
It's all a bit embarrassing, but your right testicle has swollen up gradually. You noticed it last night when you looked; though you couldn't see clearly, it seemed a bit red. You haven't noticed any change in size with coughing, straining or standing for prolonged periods.
It's stopped you from playing tennis since it's really sore. The pain started last night and is a deep sharp pain at about six out of 10. Does not radiate anywhere. You've tried ibuprofen, which has somewhat reduced the pain, but it's still there. This is associated a dragging or heavy sensation down below.
On direct questioning, you admit you've had some discharge from your penis for the last week that's white and thick. It is sore when you're passing urine. You feel a little feverish but you haven't taken a temperature to confirm. You have had no difficulty swallowing, indigestion, or weight loss.
When asked directly, you mention you are quite sexually active with 2 female partners at the moment. You try to always use condoms, but you will have the odd two or three times when you don't remember.
Ideas, Concerns, Expectations:
Though you’re concerned about not being able to play tennis and having to take time off, what you’re worried the most about is if this might affect your fertility. You ask the doctor if you’re going to need surgery.
Past Medical History:
Appendicectomy 5 years ago.
Drug History:
None.
NKDA.
Family History:
Bowel cancer (father at age 50).
Social History:
You are a professional tennis player and train 4 days a week, which involves a lot of running and physical activity.
You don't smoke and drink two bottles of wine weekly, each spread over 3-4 days.
You're an active and independent man and live by yourself.
Examination Findings:
Pulse 104bpm.
Swollen, red, warm right scrotum
Right testis tender to palpation, especially around the posterior aspect
Prehn's sign positive (relief upon elevation of the scrotum)
Cremasteric reflex intact
No hernias can be felt
Differentials:
Epididymo-orchitis (testis + epididymis swollen and tender in sexually active young man, Prehn’s sign)
Other possible differentials for swollen, tender scrotum include trauma and cellulitis.
To rule out testicular torsion (possible given active young man but pain more severe & acute, typically cremasteric reflex -ve + younger age)
Investigations:
Bedside:
Urine dipstick, MC&S
NAAT testing (chlamydia/ gonorrhoea)
Swab of urethral discharge for culture and sensitivities including gonorrhoea
Consider testing for mumps if suspected e.g.. saliva swap, serum antibodies (IgM acute infection / IgG previous infection or vaccination)
Bloods:
FBC/ CRP(infection)
Baseline Bloods e.g. U&Es, LFT, Bone Profile
Blood culture
Imaging:
Ultrasound (if unclear diagnosis, to assess for torsion/ tumour)
Management:
Consider admission for IV antibiotics for those acutely unwell/ septic
Those high risk of STIs should be referred to genitourinary medicine (GUM)
Two-week antibiotic course depending on suspected pathogen e.g. doxycycline for STI, ciprofloxacin if E.coli - as per local guidelines
Bed rest
Scrotal elevation
Analgesia
Contact tracing if sexually transmitted infection
Abstain from intercourse
Reduce physical activity
Supportive underwear
Safety net
Viva Questions:
Explain the pathophysiology of epididymo-orchitis.
Which pathogens most commonly cause epididymo-orchitis?
What are the complications of epididymo-orchitis?
If a urine dipstick revealed a positive leucocyte and negative nitrites, what does this mean?
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