What history and physical exam should be done for a 40-year-old male with dysuria and recent testicular pain, with normal ultrasound findings and negative sexually transmitted disease (STD) labs?

Evaluation of a 40-Year-Old Male with Dysuria and Recent Testicular Pain

For this 40-year-old active duty male with dysuria and recent testicular pain (with normal ultrasound and negative STD testing), you should focus your evaluation on prostatitis, chronic epididymitis, and urethral pathology as the most likely diagnoses.

History Taking

Urinary Symptom Characterization

• Onset, duration, and progression of dysuria (sudden vs. gradual onset helps differentiate infection from chronic conditions) 1, 2
• Location of pain during urination (urethral vs. bladder pain; beginning vs. end of stream) 3, 2
• Associated lower urinary tract symptoms: frequency, urgency, hesitancy, weak stream, incomplete emptying, nocturia 4
• Severity assessment using a validated symptom score if chronic symptoms are present 4

Testicular Pain Details

• Character and timing of testicular pain (constant vs. intermittent; unilateral vs. bilateral) 5
• Provocative factors: physical activity, prolonged sitting, sexual activity, bowel movements 5
• Associated symptoms: scrotal swelling, fever, penile discharge 4, 6

Infectious and Sexual History

• Recent sexual activity and new partners (despite negative STD testing in July 2025) 1, 2
• History of urinary tract infections or prostatitis 3, 6
• Recent urologic procedures or catheterization 2
• Presence of urethral discharge (timing, character, amount) 1, 3

Additional Relevant History

• Hematuria or hematospermia (gross or microscopic) 4
• Recent trauma to genitourinary area 6
• Low back pain or radicular symptoms (may cause referred scrotal pain) 5
• Previous genitourinary surgery or instrumentation 5
• Medications that could cause urethral irritation 2
• Fluid intake patterns and voiding diary for 3 days if nocturia is prominent 4

Physical Examination

Focused Genitourinary Examination

• Digital rectal examination (DRE): assess prostate size, consistency, tenderness, nodularity, and symmetry (prostatitis typically causes tenderness and boggy texture) 4
• Scrotal examination: palpate testes, epididymis, and spermatic cord for masses, tenderness, swelling, or abnormal consistency despite normal ultrasound 4
• Urethral meatus inspection: look for discharge, erythema, or lesions 1, 3
• Penile shaft and glans examination: assess for skin lesions, plaques, or areas of tenderness 1, 2

Additional Physical Findings

• Suprapubic palpation: assess for bladder distention or tenderness 4
• Inguinal examination: evaluate for hernias or lymphadenopathy 4
• Perineal and lower extremity neurologic assessment: check sensation and motor function to rule out neurogenic causes 4

Diagnostic Considerations

Primary Diagnoses to Consider

Prostatitis (most likely given age, dysuria, and testicular pain pattern):

• Chronic bacterial prostatitis or chronic pelvic pain syndrome 3, 6
• May present with dysuria, perineal/testicular discomfort, and lower urinary tract symptoms 4

Chronic epididymitis:

• Can persist despite normal ultrasound findings 5
• Often associated with dysuria and may have intermittent testicular pain 6, 5

Urethritis (including atypical organisms):

• Consider Mycoplasma genitalium if initial STD testing was negative but symptoms persist 1
• Non-gonococcal urethritis can present with dysuria alone 3, 2

Secondary Considerations

• Post-infectious urethral syndrome: symptoms persisting after treated infection 2
• Bladder neck dysfunction or bladder outlet obstruction (less common at age 40) 4
• Referred pain from lumbar spine pathology 5
• Interstitial cystitis/bladder pain syndrome if symptoms are chronic 2

Recommended Laboratory Testing

• Urinalysis with microscopy: essential to identify pyuria, hematuria, or bacteriuria 4, 1, 3
• Urine culture: mandatory given recurrent/persistent symptoms to guide antibiotic therapy 1, 2
• Post-DRE urine specimen or expressed prostatic secretions: if prostatitis suspected (look for white blood cells and bacteria) 3
• Repeat STD testing including Mycoplasma genitalium if urethritis persists with negative initial testing 1
• Uroflowmetry and post-void residual: if voiding symptoms are prominent 4

Common Pitfalls

• Assuming negative STD testing rules out all infectious urethritis: M. genitalium requires specific testing and may not be included in standard panels 1
• Overlooking chronic prostatitis: this condition frequently causes both dysuria and referred testicular pain, and DRE findings may be subtle 3, 6
• Relying solely on normal ultrasound: chronic epididymitis and early prostatitis may not show imaging abnormalities 5
• Empiric antibiotic treatment without culture: this approach increases recurrent symptoms and inappropriate antibiotic use 1