Can you write a SOAP note for a 27‑year‑old male presenting with acute left groin pain radiating to the left testicle, left epididymal tenderness, mild dysuria and clear urethral discharge, normal vital signs, and no signs of testicular torsion on examination?

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SOAP Note: 27-Year-Old Male with Left Groin Pain and Epididymal Tenderness

SUBJECTIVE

Chief Complaint: Acute left groin pain radiating to left testicle

History of Present Illness:

  • 27-year-old male presenting with acute onset left groin pain radiating to left testicle
  • Associated mild dysuria
  • Clear urethral discharge noted
  • No fever, chills, nausea, or vomiting reported
  • Sexual history: [document number of partners, recent sexual activity, condom use]
  • No recent urethral instrumentation or catheterization
  • No history of similar episodes

Review of Systems:

  • Genitourinary: Dysuria, urethral discharge, testicular pain
  • Constitutional: Denies fever, chills, malaise
  • Gastrointestinal: Denies nausea, vomiting, abdominal pain

OBJECTIVE

Vital Signs: Within normal limits, afebrile

Physical Examination:

  • General: Alert, comfortable, no acute distress
  • Abdomen: Soft, non-tender, no masses
  • Genitourinary:
    • Left epididymis: Tender to palpation, possibly enlarged
    • Left testis: Normal lie, no masses, cremasteric reflex intact
    • Right testis/epididymis: Normal, non-tender
    • Prehn's sign: [if positive, suggests epididymitis]
    • Clear urethral discharge present
    • No scrotal erythema or warmth
    • No signs of testicular torsion (normal testicular lie, intact cremasteric reflex, gradual onset)

Diagnostic Studies Ordered:

  • Urinalysis with microscopy (midstream urine)
  • Urine culture
  • Nucleic acid amplification test (NAAT) for Chlamydia trachomatis and Neisseria gonorrhoeae on first-void urine
  • Urethral swab for gonorrhea culture (given discharge)
  • Consider scrotal ultrasound with Doppler if diagnosis uncertain or to rule out complications

ASSESSMENT

Primary Diagnosis: Acute left epididymitis, likely sexually transmitted infection (STI)-related

Differential Diagnoses:

  1. Epididymo-orchitis (if testicular involvement develops)
  2. Urethritis with referred pain
  3. Testicular torsion (ruled out clinically)
  4. Inguinal hernia (less likely given examination)

Clinical Reasoning: This 27-year-old sexually active male most likely has acute epididymitis caused by sexually transmitted pathogens, specifically Chlamydia trachomatis or Neisseria gonorrhoeae. 1 The presentation of epididymal tenderness, urethral discharge, and dysuria in a young male strongly suggests STI-related epididymitis, as up to 90% of epididymitis cases result from pathogen migration from the urethra or bladder. 1 The predominant pathogens in this age group are C. trachomatis and N. gonorrhoeae, with enterobacterales being less common in sexually active young men without urinary tract abnormalities. 1

The absence of testicular torsion signs (normal testicular lie, intact cremasteric reflex, gradual onset rather than sudden, positive Prehn's sign if tested) makes torsion unlikely, though it must always be excluded first in acute scrotal pain. 2 The presence of urethral discharge further supports an infectious etiology over torsion.

PLAN

Diagnostic Plan:

  • Immediate: Urinalysis with microscopy to check for pyuria and bacteriuria
  • Send: Urine culture to identify pathogens and guide antibiotic adjustment if needed
  • Send: NAAT testing on first-void urine for C. trachomatis and N. gonorrhoeae 1
  • Send: Urethral swab for gonorrhea culture given visible discharge
  • Consider: Scrotal ultrasound with Doppler if clinical diagnosis uncertain, symptoms worsen, or abscess suspected 1

Treatment Plan:

Empiric Antibiotic Therapy (Start Today):

Given the high likelihood of gonorrhea with concurrent chlamydial infection in a sexually active young male with urethral discharge, treat empirically for both pathogens: 1

  • Ceftriaxone 1000 mg IM or IV single dose (for gonorrhea coverage)
    • Note: IV administration is increasingly supported as safe and effective while avoiding IM injection discomfort 1

PLUS

  • Doxycycline 100 mg PO twice daily for 7 days (for chlamydia and other non-gonococcal pathogens)
    • Alternative: Azithromycin 1.0-1.5 g PO single dose if compliance concerns, though doxycycline is preferred 1

Rationale: The 2024 European Association of Urology guidelines recommend ceftriaxone plus an antibiotic active against Chlamydia for epididymitis when gonorrhea is likely. 1 This dual therapy approach addresses the most common sexually transmitted pathogens in this age group and prevents treatment failure from unrecognized co-infection.

Supportive Care:

  • NSAIDs (ibuprofen 400-600 mg PO every 6-8 hours as needed) for pain and inflammation
  • Scrotal support/elevation
  • Ice packs to scrotum for comfort
  • Avoid heavy lifting and strenuous activity
  • Sexual abstinence until completion of treatment and symptom resolution

Follow-Up Plan:

  • 48-72 hours: Phone follow-up to assess symptom improvement

    • If no improvement or worsening: arrange urgent in-person evaluation with scrotal ultrasound 3
    • Critical caveat: Approximately 88% of epididymal abscesses can be treated without surgery, but serial Doppler monitoring is essential in high-risk or non-responding patients to prevent testicular necrosis 3, 4

  • 7-10 days: Return visit to confirm symptom resolution and review culture/NAAT results

    • Adjust antibiotics if needed based on sensitivities
    • If persistent symptoms after first-line therapy, consider Mycoplasma genitalium and treat with azithromycin 500 mg day 1, then 250 mg days 2-5, or moxifloxacin 400 mg daily for 7-14 days if macrolide resistance suspected 1

Partner Management:

  • All sexual partners within past 60 days require evaluation and empiric treatment for gonorrhea and chlamydia
  • Patient should abstain from sexual activity until he and all partners complete treatment and are symptom-free for 7 days
  • Counsel on safer sex practices and condom use

Patient Education:

  • Explain diagnosis of epididymitis and likely STI etiology
  • Emphasize importance of completing full antibiotic course even if symptoms improve
  • Warn about potential complications if untreated: abscess formation (rare), testicular infarction (very rare), chronic pain, or subfertility (approximately 40% risk of post-inflammatory subfertility) 4
  • Discuss STI prevention strategies
  • Advise to return immediately if fever develops, pain worsens significantly, or scrotal swelling increases (possible abscess or other complications)

Red Flags Requiring Urgent Re-evaluation:

  • Fever or systemic symptoms
  • Worsening pain despite treatment
  • Increasing scrotal swelling or erythema
  • Development of scrotal skin changes (consider Fournier's gangrene, though rare)
  • Inability to void

Common Pitfall to Avoid: Do not rely solely on inflammatory markers (WBC, IL-6) to gauge treatment response, as these may normalize while disease progresses. 3 Clinical examination and serial imaging when indicated are more reliable for monitoring treatment efficacy, particularly in patients with risk factors or severe presentation.

References

2
Research

Acute scrotal pain.

Emergency medicine clinics of North America, 1998

4
Research

[Current Aspects of Epididymo-Orchitis].

Aktuelle Urologie, 2016

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