From the Guidelines
The workup for this 47-year-old male with penile swelling after intimacy and right medial groin/thigh neurological symptoms should focus on both genitourinary and neurological causes, with an emphasis on evaluating for potential nerve root compression or vascular/lymphatic abnormalities. I recommend an MRI of the lumbosacral spine to evaluate for disc herniation or nerve root compression, particularly at L1-L2 levels which innervate the genitofemoral nerve, as suggested by the American College of Physicians and the American Pain Society 1. The patient should also undergo Doppler ultrasound of the penis to assess for lymphatic or vascular abnormalities causing the swelling. Referral to both neurology and urology is appropriate, with the neurologist evaluating the sensory symptoms in the groin and thigh, which suggest genitofemoral nerve involvement, possibly related to his previous disc issues, and the urologist assessing the penile swelling, which may represent lymphedema or a vascular reaction. Electromyography (EMG) and nerve conduction studies may help confirm nerve involvement, as recommended for patients with suspected radiculopathy or spinal stenosis 1. The temporal relationship between symptoms and sexual activity, along with their simultaneous onset, suggests a potential mechanical trigger during intercourse that may be compressing nerve roots or affecting vascular/lymphatic drainage. While continuing ibuprofen for symptom management, the patient might benefit from pelvic floor physical therapy and possibly a trial of neuropathic pain medication such as gabapentin if nerve compression is confirmed, as suggested by the American Urological Association guideline on erectile dysfunction 1. Additionally, the patient's history of back strain and bulging discs 23 years ago should be considered in the context of his current symptoms, and further evaluation and management should be guided by the findings of the recommended diagnostic tests and specialist referrals.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. The patient is already on ibuprofen 600mg prn.
- The workup for this patient's condition is not directly addressed in the provided drug label.
- The imaging studies that may be necessary are not mentioned in the label.
- Possible referral to a specialist, such as a urologist or neurologist, may be considered to further evaluate the patient's symptoms, but this is not explicitly stated in the label 2.
From the Research
Workup and Imaging
- The patient's symptoms of intermittent right-sided penile swelling, redness, and numbness in the right medial groin extending to the inner anterior thigh, suggest a possible neuropathic pain condition 3.
- A thorough neurological examination, including an assessment of consciousness, cognition, brainstem function, and motor function, is essential in evaluating the patient's condition 4.
- Imaging studies, such as ultrasound, may be useful in diagnosing and guiding therapy for neuropathic pain conditions, particularly in cases where Morton's neuroma or piriformis syndrome is suspected 5.
- Given the patient's history of back strain and bulging discs, imaging studies of the spine, such as an MRI, may also be considered to rule out any underlying spinal conditions that could be contributing to the patient's symptoms.
Possible Referral
- The patient's symptoms and history suggest that a referral to a pain management specialist or a neurologist may be beneficial in further evaluating and managing the patient's condition 6, 7.
- A pain management specialist can help to develop a comprehensive treatment plan, including pharmacological and non-pharmacological interventions, to manage the patient's neuropathic pain.
- A neurologist can help to further evaluate the patient's neurological symptoms and determine if there are any underlying neurological conditions that need to be addressed.
Treatment Options
- The patient is currently being treated with ibuprofen 600mg prn, but other treatment options, such as anticonvulsants (e.g. gabapentin, pregabalin) or tricyclic antidepressants, may be considered for managing the patient's neuropathic pain 6, 7.
- Topical agents, such as capsaicin or lidocaine, may also be considered for managing localized pain and numbness 7.
- A multidisciplinary approach, including physical therapy, cognitive-behavioral therapy, and other non-pharmacological interventions, may also be beneficial in managing the patient's condition.