(Answered 2023) Emergency Medicine Genitourinary Exam
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- A 19-year-old man presents to the ED with pain along his penile shaft for the
past 7 days. He reports a low-grade fever and myalgias and was sexually active with a new partner 10 days ago. He denies any penile discharge or dysuria.There is no inguinal adenopathy palpated on exam, but he has tender penile lesions, revealed in the image seen above. Which of the following is most likely to be an effective treatment?
Acyclovir PO Ceftriaxone IM Doxycycline PO Penicillin G IM
Answer: ( A )
Explanation:
This is a patient with a primary herpes infection, characterized by a low-grade fever; myalgias; and multiple painful, shallow, tender, genital lesions. These typically follow a 2-7-day incubation period. Patients often do not have adenopathy until the 2nd or 3rd week of illness. Lesions last for 2-4 weeks.Treatment is acyclovir to reduce the duration of symptoms and viral shedding.Ceftriaxone (B) is one of several treatment regimens for chancroid. Although chancroid also presents with painful genital ulcers, 50% of patients also develop a large unilateral, fluctuant lymph node (bubo) 1 week after the ulcers appear. It is often difficult to differentiate herpes from chancroid on exam.However, herpes is orders of magnitude more common in the United States; most cases of chan- croid occur in developing countries. There are usually fewer than 100 cases of chancroid reported to the CDC annually. Therefore, in patients such as this one, herpes should be of primary consideration, and acyclovir is more likely to be an effective treatment. Doxycycline (C) is used to treat lymphogranuloma venereum. However, lesions are painless and often go 1 / 4
unnoticed. Patients often present in the secondary stage following the disappearance of genital lesions, when they develop painful lymphadenitis.Penicillin (D) would be the appropriate treatment for syphilis. However, the incubation period is typically longer and primary lesions (chancres) are painless with raised edges.
- One Step Further
Question: What is the utility of a Tzanck test?
Answer: Tzanck tests are no longer recommended due to poor sensitivity.
- A 48-year-old man presents with fever and an acutely painful scrotum. He has
significant pain during testicular palpation. A cremasteric reflex is pre- sent and Doppler ultrasonography shows an enlarged, thickened epididymis with increased blood flow to the left testicle. There is no discharge from the urinary meatus. Which of the following is the most appropriate antibiotic for this condition?
Ceftriaxone plus doxycycline Doxycycline alone Levofloxacin Penicillin
Answer: ( C )
Explanation:
Epididymitis occurs most commonly in men between the ages of 14 and 35 years. However, it can occur in any age group. It occurs from an ascending infection from the urethra, prostate, or bladder, and occasionally by hematogenous spread. Epididymitis is characterized by gradually increasing dull, unilateral scrotal pain, fever, and dysuria. Examination usually reveals localized epididymal edema and tenderness (posterior aspect of scrotum), possible testicular tenderness, and a normal cremasteric reflex. Pain may be relieved with testicular elevation (positive Prehn sign). Scrotal pain should be 2 / 4
initially evaluated with a color Doppler ultra- sound test, and in the case of epididymitis, the typical findings are an enlarged, thickened epididymis with increased blood flow. The most common organisms re- sponsible for epididymitis in those 14 to 35 years-of-age are Neisseria gonorrhoeae and Chlamydia trachomatis. In older individuals (traditionally >35 years of age) and nonsexually active individuals, the Gram-negative rod bacteria (Escherichia, Klebsiella, Enterobacter and Citrobacter species) are most common. Trimetho- prim-sulfamethoxazole or a fluoroquinolone such as levofloxacin or ciprofloxacin is the recommended treatment in this age group.
Ceftriaxone plus doxycycline (A) is the treatment of choice for suspected orchitis or epididymitis in men between the ages of 14 and 35 years.Doxycycline alone (B) is not recommend as the sole antibiotic for orchitis in any age group. Penicillin (D) is more appropriate for streptococcal or staphylococcal infections, both of which are not common etiologies of orchitis or epididymitis.
- One Step Further
Question: Does the presence of Prehn's sign rule out testicular torsion?
Answer: No.
- Which of the following is one of the most helpful signs to rule out testicular
torsion?Presence of a bell-clapper deformity Presence of Prehn's sign (relief of scrotal pain upon elevation of scrotum) Presence of the cremasteric reflex Vertical lie of testicle
Answer: ( C )
Explanation:
The cremasteric reflex is a superficial reflex elicited by lightly stroking the superior and medial (inner) thigh in a male. The normal response is an immediate contrac- tion of the cremaster muscle that pulls up the testis (>0.5 3 / 4
cm) on the side stroked. The presence of a cremasteric reflex appears to be one of the most helpful signs in ruling out testicular torsion. The cremasteric reflex may be absent in conditions such as testicular torsion, upper and lower motor neuron disorders, spinal injury of L1-L2, and iatrogenic transection of the ilioinguinal nerve during surgery for hernia repair. Despite being one of the most helpful signs, it is important to note that the presence of a cremasteric reflex cannot rule out testicular torsion with 100% certainty.The bell-clapper deformity (A) is an entity in which the tunica vaginalis completely encircles the epididymis, distal spermatic cord, and the testis rather than attaching to the posterolateral aspect of the testis. This causes the testicle to hang free within the tunica vaginalis, in a horizontal fashion. This anatomic abnormality predisposes to spermatic cord torsion. Relief of pain with elevation of a painful testicle represents a positive Prehn's sign (B) and points toward a diagnosis of epididymitis rather than testicular torsion. It is thought that by elevating the painful testicle, the pain of epididymitis improves because the elevation takes the weight of the testis off the epididymal suspension but does not affect the testicle in cases of testicular torsion. However, Prehn's sign is unreliable and should not be used to rule out testicular torsion. Although a vertical lie (D) of the testicle is normal, it does not rule out testicular torsion
- One Step Further
Question: What age is testicular torsion most likely to occur?
Answer: Bi- modal distribution with peak incidence in the neonate within
first few days of life and in preadolescence
- Which of the following is associated with an increased likelihood of tes-
ticular torsion?
Age greater than 50 years Epididymitis
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