Week 3 - Pain in groin

Question 1

J.S. is a 21 year old male University student. He presents at 23.30 to ED, worried and embarrassed and asks if he can see the doctor. He has a pain in his groin.

Take a history of this patient.

HPC:
• Left scrotal/groin pain, 12 hours, constant, gradually worsened, severity 2 to 5/10.
• No Hx of trauma, pressure or lifting any weight.
- To exclude any hernias.
• No appetite, feels crook, a bit ‘viral’ and a bit feverish.
- ?Infection.
• Urine normal but some dysuria, mild discomfort.
• Unsure if uretheral discharge, no haematuria.
• Sexually active, multiple partners, no condom use, no male partners.
• O/E: L scrotum enlarged, inflamed, pain, tender. Epididymis feels a little thickened and is painful.
- ?Epididymo-orchitis.
• Relief of pain occurs on elevation of scrotum*
• No inguinal lymph nodes, no hernia, no organomegaly.

Answer 1

• Site
• Onset
• Character
• Radiation
• Alleviating factors
• Timing - experienced it before, constant or intermittent, how long does it last, worse at a particular time?
• Exacerbating factors
• Severity
• Associated symptoms
• Effect on lifestyle.

Torsion:
• Sudden onset pain in one testis, makes walking uncomfortable, pain in abdomen, nausea, vomiting.
• Tender, hot and swollen testis. May lie high and transversely.

Epididymo-orchitis:
• Sudden onset tender swelling, dysuria, sweats/fever.
• Patient tends to be older and there may be symptoms of urinary infection. More gradual onset of pain.

Hernia:
• History of trauma, pressure, lifting heavy things.
• Chronic cough, constipation, urinary obstruction, heavy lifting, ascites, past abdominal surgery.

Genitourinary:
• Haematuria, change in colour/odour, dysuria.

STD:
• Partners
- Number, gender, length of relationship. Ask about partner’s risk factors such as current/past sex partners or drug use.
- Are you currently sexually active?
- In recent months, how many sex partners have you had?
- In the past 12 months, how many sex partners have you had?
- Are your sex partners men, women or both?

• Practices

• I am going to be more explicit here about the kind of sex you’ve had over the last 12 months to better understand if you are at risk for STDs.
• What kind of sexual contact do you have or have you had? Genital (penis in the vagina)? Anal (penis in the anus)? Oral (mouth on penis, vagina or anus)?

• Protection from STDs

• Do you and your partner(s) use any protection against STDs? If not, could you tell me the reason?
• If so, what kind of protection do you use?
• How often do you use this protection?
• If ‘sometimes,’ in what situations or whom do you use protection?
• Do you have any other questions or are there other forms of protection from STDs that you would like to discuss today?

• Past history of STDs

• Have you even been diagnosed with an STD? When? How were you treated?
• Have you had any recurring symptoms or diagnoses?
• Have you even been tested for HIV, or other STDs? Would you like to be tested?
• Has your current partner or any former partners ever been diagnosed or treated for an STD? Were you tested for the same STD(s)?
• If yes, when were you tested? What was the diagnosis? How was it treated?

• Prevention of pregnancy

• Are you currently trying to conceive or father a child?
• Are you concerned about getting pregnant or getting your partner pregnant?
• Are you using contraception or practicing any form of birth control? Do you need any information on birth control?
• What other things about your sexual health and sexual practices should we discuss to help ensure your good health?
• What other concerns or questions regarding your sexual health or sexual practices would you like to discuss?

PMHx:
• Past medical history of torsion, epidymo-orchitis, hernia, STD, appendicitis?

PSHx:
• Any recent surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment.

Immunisations:
• E.g. Fluvax, pneumococcal.

FHx:
• Any family history of torsion, epidymo-orchitis, hernia, STD, appendicitis?

SHx:
• Background? 
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs? 
• Physical activity?

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands.
2. General inspection: uncomfortable, pain/distress, sweating.

3. Vitals signs:
• HR.
• BP.
• RR.
• Temp - may be febrile.
• BMI.

4. Abdomen:
   • Inspection - previous scars, skin lesions, abdominal distension, prominent veins, visible masses/lump/pulsations, visible peristalsis.
   • Palpation - light and deep (tenderness - rebound, guarding, rigidity), organomegaly, paraortic lymph nodes, inguinal lymph nodes.
   - Tests for peritonism - rebound tenderness, cough, jump on spot.
   • Percussion
   • Auscultation - bowel sounds.
5. Genitals:
   • Inspection (standing and supine): erythema, swelling, trauma/deformity, sores, ulcers, rashes, discharge, asymmetry (elevated/horizontal in torsion).
   • Palpation - tenderness, warmth, isolation of structures - testes, spermatic cord, epididymis (tenderness/thickness). Any lumps/masses - can you palpate above them (inguinal hernia).
   • Transillumination test - hydrocele.

Question 3

What is your provisional and differential diagnoses?

Answer 3

• Provisional diagnosis: Epididymo-orchitis.
• DDx:
- STD.
- Hernia (inguinal).
- Torsion.
- Appendicitis.
- Epididymal cyst.
- Hydatid of Morgagni (remnant of Müllerian duct - epididymal appendage).

Question 4

What investigations would you carry out on this patient?

Answer 4

• First-catch urine → Urine PCR - chlamydia, gonorrhoea, mycoplasma genitalium.
• FBC.
• Bloods - Hep B/C, HIV, syphilis.
• Uretheral swab - if discharge.
• Doppler USS may demonstrate lack of blood flow to testis, as may isotope scanning. Only perform if diagnosis is equivocal - do not delay surgical exploration. Time dependent (<6 hours) - shows no flow in testicular artery.

Question 5

What treatment does this patient require?

Answer 5

• If <35 years, doxycycline 100mg/12h (covers chlamydia, treat sexual partners).
• If gonorrhoea suspected, add ceftriaxone 500mg IM stat.
• If >35 years (mostly non-STI), associated UTI is common so try ciprofloxacin 500mg/12h or ofloxacin 200mg/12h. Antibiotics should be used for 2-4 weeks.
• Also analgesia, scrotal support, drainage of any abscess.