The correct answer is A. This patient has epididymitis, most likely caused by Chlamydia trachomatis . Epididymitis refers to inflammation of the epididymis, which leads to unilateral intra-scrotal pain, swelling, and fever. Elevation of the affected testis usually relieves the pain to some extent (Prehn sign). Asymptomatic urethritis can be associated with epididymitis caused by C. trachomatis or Neisseria gonorrhoeae . Urinalysis may reveal pyuria. Urethral culture, urine polymerase chain reaction (PCR), or ligase chain reaction (LCR) can confirm the diagnosis. Treatment is azithromycin, doxycycline, or tetracycline. The sexual partners should be treated to avoid reinfection.
Prostatitis (choice B) is the inflammation of the prostate, which often presents with perianal and low back pain, urinary frequency, urgency, and pain during urination. Treatment is antibiotics.
Testicular torsion (choice C) is a surgical emergency that is caused by twisting of the spermatic cord and vascular compromise. It typically occurs in young adult males who present with acute unilateral testicular pain and normal urinalysis results. Testicular support does not relieve the pain.
Urethritis (choice D) is most often caused by Chlamydia trachomatis or Neisseria gonorrhoeae; it presents with a urethral discharge. The discharge is mucoid in chlamydial infection and purulent in gonorrhea. Treatment is ceftriaxone and doxycycline. Sexual partners should be treated.
Varicoceles (choice E) are a collection of veins that feel like a "bag of worms." Surgery is indicated if there is infertility or pain. They are more common on the left side.
PEARL: Chlamydia trachomatis is the most common cause of bacterial epididymitis in men age <35. Older men typically have epididymitis caused by E. coli infection. Gonococcal infection is less common and would most likely be found on urinalysis using a first morning void sample. E. coliand other gram-negative rods are the most common cause in older men. Urethral discharge is typically seen with urethritis.
