Special Operations Forces Medical Handbook

3-84

Follow-up Actions
Wound Care: Light activity for 3-4 weeks after surgery.
Return evaluation: If the testis was salvaged, the risk for shrinkage or atrophy increases with the length
of time the testis was torsed.
Evacuation/Consultation Criteria: All cases of suspected torsion should be referred. The patient is at risk
for torsion on the opposite side as well. He should be evacuated as soon as possible to prevent this calamity,
particularly if one testis was not salvaged. The testes both need to be surgically explored and fixed to the
scrotal wall to prevent rotation. Loss of both testes results in significant hormonal changes and infertility and
should be avoided.

Symptom: Male Genital Problems: Epididymitis

CAPT Leo Kusuda, MC, USN

Introduction: The epididymis, usually located behind each testis, is the site of final maturation and storage
of sperm. It can become painful from either mechanical or infectious irritation. Treatment involves both
medication and scrotal support which may require strict bedrest in severe cases. Prior vasectomy is a risk
factor (epididymal pain can develop 8-10 years post-vasectomy)

Subjective: Symptoms
Pain in the scrotum behind the testis with tenderness of the epididymis, and without pain in the testis.

Objective: Signs
Using Basic Tools: Marked swelling of the hemi-scrotum, urethral discharge, frequent and urgent urination,
fever. Use penlight or otoscope to transilluminate the scrotum to differentiate swelling due to a mass vs. fluid
(bright, diffuse glow; seen with spermatocele or hydrocele).
Using Advanced Tools: Lab: Urinalysis: nitrite and leukoesterase positive urine (infection). Do urine culture
if available and dipstick is positive. Gram stain urethral discharge to screen for gonorrhea and chlamydia.

Assessment:

Differential Diagnosis (see the appropriate topics in this book)
Pain and tenderness in other areas of the scrotum, such as the cord or groin, of equal or greater severity would
suggest other causes of the pain such as hernia, varicocele, musculoskeletal pain or entrapped nerve.
An abnormal testis on physical exam may suggest tumor, appendix testis, viral orchitis, testis trauma or testis
torsion. Recurrent symptoms lasting less than 1 day are much more suggestive of intermittent testicular
torsion.

Plan:
Treatment
Primary:

1. Scrotal support/elevation, bedrest.


2. NSAIDs such as ibuprofen 800 mg po tid with food.


3. If the urine is nitrite and leukoesterase positive, treat with antibiotics.
   a. If a fever is present and there is no urethral discharge, give:
   Levaquin 500 mg po bid x 10 days or Septra DS 1 po bid x 30 days.
   In severe cases ampicillin 1 gm IV q6h plus gentamicin (loading dose of 1.5 mg/kg followed by
   1 mg/kg IV q8h) or Rocephin 5 mg/kg IV qd (ceftriaxone 500 mg to 1gm IV bid) should be given until
   fever resolves, then convert to oral antibiotics (above).
   b. If there is a urethral discharge and no fever, give ceftriaxone 250 mg IM (or Cipro 500 mg po or Floxin
   400 mg po) single dose to treat gonorrhea, and follow with 7-10 days of doxycycline 100 mg po bid (or
   Floxin 400 mg po qd or Levaquin 500 mg po qd).
   c. If both fever and urethral discharge are present, treat for disseminated gonorrhea: ceftriaxone 1 gm