What is the next step in managing a male gay patient with symptomatic testicular swelling and increased urinary urgency, who engages in anal sex, without reported discharge, fever, or pelvic pain, and is undergoing STI (Sexually Transmitted Infection) screening?

Management of Testicular Swelling and Urinary Urgency in MSM Patient

Immediate Priority: Rule Out Testicular Torsion

You must urgently exclude testicular torsion before proceeding with STI workup alone, as this is a surgical emergency requiring intervention within 6-8 hours to prevent testicular loss. 1, 2

• Testicular torsion is more common in adolescents but can occur in adults, and presents with sudden onset of severe unilateral testicular pain 1, 3
• The absence of fever does NOT rule out torsion—normal urinalysis and lack of systemic symptoms are actually consistent with torsion 3
• If pain onset was sudden or severe, arrange immediate urological consultation 1
• If clinical suspicion exists, order Duplex Doppler ultrasound emergently (sensitivity 69-96.8%) to assess testicular blood flow 2, 3

Most Likely Diagnosis: Acute Epididymitis

In sexually active MSM patients with testicular swelling and urinary urgency, acute epididymitis is the most probable diagnosis, requiring empiric antibiotic therapy covering both STI pathogens and enteric organisms. 1, 2

Diagnostic Workup Beyond STI Screen

You need additional testing beyond standard STI screening:

• Urethral Gram stain or intraurethral swab looking for >5 polymorphonuclear leukocytes per oil immersion field to diagnose urethritis 1
• First-void urine examination for leukocytes if urethral Gram stain is negative 1
• Urine culture with Gram stain of uncentrifuged urine 1
• Syphilis serology (which you're likely already doing with STI screen) 1

Critical Consideration for MSM Patients

In MSM who practice receptive anal intercourse, enteric organisms (particularly E. coli) are common causes of epididymitis, not just gonorrhea and chlamydia. 1

• This occurs because enteric bacteria colonize the urethra through insertive anal intercourse 1, 4
• Standard STI-only coverage (ceftriaxone + doxycycline) may be insufficient 1

Empiric Treatment Recommendation

Start dual coverage immediately while awaiting culture results:

Option 1 (Preferred for MSM with anal intercourse history):

• Ofloxacin 300 mg orally twice daily for 10 days 1
• OR Levofloxacin 500 mg orally once daily for 10 days 2
• This covers gonorrhea, chlamydia, AND enteric organisms 1

Option 2 (If fluoroquinolone contraindicated):

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1
• However, this may miss enteric organisms 1

Adjunctive Measures:

• Bed rest, scrotal elevation, and NSAIDs until fever and inflammation subside 1, 2

Telehealth Limitations and Safety Net

Via telehealth, you cannot adequately assess for testicular torsion or perform necessary physical examination maneuvers (Prehn sign, epididymal palpation). 2, 3

You must instruct the patient to:

• Seek emergency evaluation immediately if: pain suddenly worsens, becomes severe, or if he develops nausea/vomiting 1, 3
• Go to emergency department if no improvement within 3 days of starting antibiotics 1
• Consider in-person evaluation within 48-72 hours to confirm diagnosis and assess response 2

Partner Management

All sexual partners within the past 60 days require evaluation and empiric treatment regardless of symptoms 1

• Partners should receive the same antibiotic regimen 1
• Patient must abstain from sexual activity until both he and partners complete therapy and are asymptomatic 1

Additional Screening Considerations

Since patient is MSM, ensure your STI screen includes:

• Rectal gonorrhea and chlamydia testing (most rectal infections are asymptomatic) 5, 6
• HIV testing if not recently done 1
• Hepatitis A, B, and C serology 7

Common Pitfalls to Avoid

• Don't rely solely on urinalysis—it may be normal in STI-related epididymitis, as urethral pathogens (not urinary bacteria) are the source 2
• Don't assume standard STI coverage is adequate in MSM practicing receptive anal intercourse—enteric organisms require fluoroquinolone coverage 1, 4
• Don't continue telehealth management if patient doesn't improve in 3 days—persistent symptoms require ultrasound to exclude abscess, tumor, or testicular cancer 1
• Don't forget that absence of urethral discharge doesn't exclude urethritis—it's often asymptomatic in epididymitis 1