What is the appropriate initial evaluation and management for a male patient with acute severe groin pain that worsens with urination?

Acute Severe Groin Pain in Males Worsening with Urination

This presentation most likely represents renal colic from urolithiasis, and you should immediately provide intramuscular diclofenac 75 mg for rapid pain control while simultaneously evaluating for life-threatening alternative diagnoses. 1

Immediate Assessment (Within 30 Minutes)

Time-sensitive evaluation is critical—patients with acute symptoms require medical assessment within 30 minutes. 1

Key Diagnostic Features to Establish

• Classic renal colic presentation: Abrupt onset of severe unilateral flank pain radiating into the groin or genitals, often worsening with urination as the stone moves through the ureter 1, 2
• Vital signs assessment: Check pulse, blood pressure, and temperature to exclude shock and systemic infection—patients with fever or shock require immediate hospital admission 1
• Abdominal examination: Palpate to identify maximal tenderness location and exclude peritonitis, which would indicate alternative pathology 1

Critical Alternative Diagnoses to Exclude

• If patient is over 60 years: Consider leaking abdominal aortic aneurysm as a life-threatening mimic 1
• Urological emergencies: Testicular torsion (acute scrotal pain/swelling), acute epididymitis (fever, scrotal tenderness), or urethral injury (blood at meatus, inability to void) 1, 2

Urinalysis Considerations

• Haematuria supports renal colic diagnosis (present in >80% of cases), but absence does not exclude it 1
• Practical limitation: Many patients cannot void on demand during acute pain, so do not delay treatment waiting for urinalysis 1

Immediate Pain Management

Analgesia must be administered to achieve pain relief within 30 minutes—this is the highest priority after excluding emergencies. 1

First-Line Treatment

• Diclofenac 75 mg intramuscular injection is the preferred analgesic for renal colic 1
• Intramuscular route is essential: Oral and rectal routes are unreliable during acute pain; intravenous is impractical in primary care 1

Alternative if NSAIDs Contraindicated

• Morphine sulfate with cyclizine (antiemetic) should be given if NSAIDs are definitively contraindicated 1

Response Assessment

• Telephone follow-up at 1 hour: If pain persists despite analgesia, arrange immediate hospital admission by phone without requiring a second visit 1
• Abrupt recurrence of severe pain after initial relief also warrants immediate admission 1

Diagnostic Imaging Strategy

If Hemodynamically Stable

• CT scan with IV contrast of abdomen/pelvis is the gold standard to identify stone location, size, and degree of obstruction 1
• Imaging should occur within 7 days of symptom onset for optimal diagnostic accuracy 1

If Hemodynamically Unstable

• Chest X-ray and E-FAST ultrasound to rule out extra-pelvic bleeding sources before proceeding to angiography if needed 1

Specific Considerations for Pain with Urination

When to Suspect Lower Urinary Tract Pathology

• Clinical red flags: Inability to urinate, gross hematuria, blood at urethral meatus, suprapubic tenderness, or suprapubic penetrating wounds 1
• If these symptoms present: Perform retrograde urethral and bladder opacification with CT scan before attempting urinary catheterization to avoid worsening urethral injury 1

Urethritis Differential

• If dysuria is the primary symptom (rather than colicky flank pain), consider gonococcal or non-gonococcal urethritis and obtain urethral swab for culture 1
• Epididymitis presentation: Pain, swelling, and elevated temperature of epididymis, potentially involving testis—requires different antibiotic management 1

Home Management Instructions (If Pain Controlled)

• High fluid intake: Instruct patient to drink large volumes of fluid 1
• Strain urine: Void into container or through tea strainer/gauze to catch any passed stone for analysis 1
• Contact instructions: Call immediately if pain worsens or new distressing symptoms develop 1

Mandatory Hospital Admission Criteria

• Failure of analgesia within 1 hour 1
• Fever or signs of systemic infection (suggests infected obstructed system—urological emergency) 1
• Hemodynamic instability (shock, hypotension) 1
• Inability to tolerate oral fluids or intractable vomiting 1

Follow-Up and Prevention

Short-Term Follow-Up

• Telephone call 1 hour post-assessment to verify pain control 1
• Urology referral within 7-14 days if stone identified on imaging requiring potential intervention 1

Long-Term Stone Prevention

• Increase fluid intake to produce ≥2 liters urine daily as primary prevention strategy 3
• If recurrent stones develop: Consider thiazide diuretic, citrate, or allopurinol based on stone composition 3
• Annual imaging for asymptomatic nonobstructing stones 3

Common Pitfalls to Avoid

• Do not delay analgesia while pursuing diagnostic workup—pain control within 30 minutes is a Grade A recommendation 1
• Do not assume typical presentation in elderly patients—atypical symptoms like confusion or falls may represent serious pathology 3
• Do not attempt urethral catheterization in males with blood at meatus or inability to void without first performing retrograde urethrography to exclude urethral injury 1
• Do not discharge patients over 60 years without carefully excluding abdominal aortic aneurysm 1