the most common misdiagnosis for testicular torsion. Epididymitis is gener-
ally a disease of adult men. The causative organism in men over 35 years old
isE coli,whileC trachomatisandNeisseria gonorrhoeaepredominate in men
less than 35 years old. The older patient may have a history of gonococcal
urethritis (GU) tract manipulation or a history of prostatitis. The onset is
usually gradual and urinary tract symptoms may precede the pain.
Testicular torsion (b)should always be on the differential for a patient
with scrotal pain. However, it is ruled out in this patient by the presence of
blood flow on color Doppler. UTIs in men (c),in the absence of trauma or
instrumentation are rare. Scrotal pain is usually not present. Testicular
tumors(d)are often mistakenly diagnosed as epididymitis. They usually
occur in middle-aged men and have a higher prevalence in patients with
cryptorchidism. Color Doppler can often distinguish a tumor from epi-
didymitis. A varicocele (e)is a painless scrotal swelling that is caused by
dilation and elongation of the veins of the pampiniform plexus. Varicocele
is more common on the left side because the left spermatic vein drains into
the left renal vein, whereas the right one drains into the inferior vena cava.
Individuals may be asymptomatic or complain of a scrotal pain or heavi-
ness. It is thought that varicoceles may decrease sperm production.
95.The answer is a.(Rosen, pp 1413-1414.)Dysuria in young men is
almost always because of urethritis,which is commonly caused by a
sexually transmitted disease.Urethritis is classically divided into gonococ-
cal (GU) and nongonococcal (NGU) types. GU is caused by N gonorrhoeae,
while the major pathogen in NGU is C trachomatis.Nearly all men with GU
have purulent urethral discharge. NGU may be asymptomatic or with a yel-
low, mucopurulent discharge. It was demonstrated in multiple studies that
the two pathogens coexist in men with urethritis up to 50% of the time.
Therefore, antibiotics should be directed at eliminating both organisms. A
third-generation cephalosporin or ciprofloxacin as a one-time dose is used to
treat GU. Common antibiotics used to treat NGU include azithromycin as a
single dose and doxycycline or erythromycin for 7 days.
(b)This choice might be correct if you suspect a patient has UTI.
However, a young man with dysuria and urethral discharge needs to be
treated for a sexually transmitted disease. (c)The patient should not be dis-
charged prior to treatment and culture. In addition, the patient should refer
all of their sexual partners for evaluation and treatment. (d and e)There is
no clinical suspicion for a kidney stone or testicular cancer.
114 Emergency Medicine