What is the best course of action for a 38-year-old male with sharp abdominal pain radiating to the groin and testicles, recent onset of reflux, black lesions on the penis, facial erythema, and morning foot pain, with a history of treated penile infection and normal hernia evaluations?

Management of Persistent Groin-to-Testicular Pain After Normal Hernia Evaluation

This patient requires urgent surgical consultation to rule out occult inguinal hernia with dynamic imaging or diagnostic laparoscopy, as persistent groin-to-testicular pain with functional impairment despite negative static ultrasound strongly suggests a clinically significant hernia that manifests only under increased intra-abdominal pressure.

Immediate Diagnostic Priorities

Re-evaluate for Occult Hernia with Dynamic Assessment

• Static ultrasound has significant limitations for detecting hernias that only manifest during Valsalva or physical exertion; the patient's pain pattern (sharp pain radiating to groin/testicles specifically when lifting heavy objects) is pathognomonic for inguinal hernia despite negative imaging 1
• Request standing/Valsalva ultrasound or CT herniography to capture herniation during increased intra-abdominal pressure, as supine imaging misses dynamic hernias in up to 30% of cases 1
• Consider diagnostic laparoscopy if dynamic imaging remains negative but clinical suspicion persists, given the severe functional impairment (inability to work, play with children, or move furniture) 1

Rule Out Necrotizing Infection of Penile Lesions

• The "black lesions" on the penis require immediate assessment for Fournier's gangrene or necrotizing soft tissue infection, particularly given the groin pain and recent penile infection history 1, 2
• Examine for cutaneous manifestations including erythema, subcutaneous crepitations, patches of gangrene, foul smell, purulence, and tenderness extending from penis to groin 1, 2
• If any signs of necrotizing infection are present: obtain complete blood count, serum creatinine, inflammatory markers (C-reactive protein, procalcitonin, lactate), and consider LRINEC score 1, 2
• Immediate surgical debridement is required if Fournier's gangrene is suspected—do not delay for imaging if clinical signs are present 1, 2

Address the Penile Lesions Based on Appearance

• If black lesions are dry, well-demarcated, and non-tender: likely post-herpetic hyperpigmentation or residual lesions from treated HSV infection 3
• If lesions are moist, malodorous, or associated with tissue breakdown: consider secondary bacterial or fungal superinfection requiring culture and targeted antimicrobial therapy 3, 4
• Biopsy any persistent, atypical, or enlarging penile lesions to exclude squamous cell carcinoma in situ (erythroplasia of Queyrat), as these can present as benign-appearing plaques 3
• Re-evaluate syphilis serology if not previously done, as atypical syphilis presentations (Follmann balanitis) can mimic HSV and present with unusual penile lesions 5

Management of Reflux Symptoms

Initiate Aggressive GERD Treatment

• Start twice-daily PPI therapy (omeprazole 40 mg twice daily or equivalent) for 8-12 weeks combined with lifestyle modifications for the recent-onset reflux with sleep disturbance 1, 6
• Avoid eating within 2-3 hours of lying down and elevate head of bed by 6-8 inches to reduce nocturnal reflux 6
• Add alginate-containing antacids for postprandial symptoms (belching after eating late) 6
• If symptoms persist after 8-12 weeks of optimized therapy, perform upper endoscopy and 96-hour wireless pH monitoring off PPI to objectively document GERD 1

Management of Morning Foot Pain

Treat Presumed Plantar Fasciitis

• The 3-week history of morning foot pain upon standing that resolves by midday is classic for plantar fasciitis (not directly addressed in provided evidence but standard clinical knowledge)
• Recommend stretching exercises, NSAIDs, and supportive footwear
• Consider physical therapy referral if conservative measures fail after 6-8 weeks

Management of Facial Erythema

Evaluate for Rosacea or Seborrheic Dermatitis

• Ongoing facial erythema requires dermatologic assessment to determine if related to systemic condition or isolated dermatologic issue (not directly addressed in provided evidence)
• Consider topical metronidazole or azelaic acid for rosacea if that is the diagnosis

Critical Next Steps Algorithm

1. Within 24-48 hours: Surgical consultation for dynamic hernia evaluation (standing ultrasound, CT herniography, or diagnostic laparoscopy consideration) given severe functional impairment 1

2. Immediate (same visit): Careful examination of penile lesions for signs of necrotizing infection; if present, obtain labs and emergency surgical consultation 1, 2

3. Same visit: Initiate twice-daily PPI therapy and lifestyle modifications for GERD 1, 6

4. Follow-up in 2 weeks: Reassess penile lesions; if not improving or worsening, obtain biopsy and repeat STI screening including syphilis 3, 5

5. Follow-up in 8-12 weeks: Reassess GERD symptoms; if persistent, proceed to endoscopy and pH monitoring 1

Common Pitfalls to Avoid

• Do not dismiss groin-to-testicular pain with negative static imaging—hernias are dynamic and require provocative testing 1
• Do not attribute all penile lesions to treated HSV—secondary infections, atypical syphilis, and malignancy must be excluded 3, 5
• Do not delay surgical evaluation for suspected necrotizing infection—mortality increases dramatically with delayed debridement 1, 2
• Do not continue empiric PPI therapy beyond 12 months without objective GERD documentation via endoscopy and pH monitoring 1