A male patient has persistent scrotal pruritus and nocturnal dysuria, reports that spicy foods trigger burning while milk/dairy do not, has been self‑administering albendazole twice weekly and using topical scrotal powders—what is the most likely diagnosis and how should it be evaluated and treated?

Likely Diagnosis and Management of Persistent Scrotal Pruritus with Nocturnal Dysuria

This patient most likely has epididymitis with possible concurrent parasitic infection (enterobiasis), and requires immediate cessation of albendazole, proper diagnostic workup including urethral swab/urine testing for sexually transmitted infections and enteric organisms, and age-appropriate empiric antibiotic therapy while awaiting culture results. 1, 2

Critical Diagnostic Evaluation Required

Immediate Testing for Epididymitis

• Obtain Gram stain of urethral exudate or intraurethral swab showing ≥5 polymorphonuclear leukocytes per oil immersion field to confirm urethritis 1, 3
• Perform nucleic acid amplification testing on first-void urine or urethral swab for Neisseria gonorrhoeae and Chlamydia trachomatis 1, 3
• If urethral Gram stain is negative, examine first-void uncentrifuged urine for leukocytes with culture and Gram stain 1
• Order syphilis serology and offer HIV counseling and testing 1, 2

Physical Examination Findings to Document

• Assess for unilateral testicular pain and tenderness, hydrocele, and palpable swelling of the epididymis—these findings are typical of epididymitis 1
• Rule out testicular torsion immediately if pain onset was sudden or severe, as this is a surgical emergency requiring specialist consultation within hours to preserve testicular viability 1, 3, 2

Parasitic Infection Consideration

The patient's self-administration of albendazole twice weekly is inappropriate and suggests he suspects pinworm infection. While ectopic enterobiasis causing scrotal symptoms is documented in case reports, this is extremely rare and should not delay treatment of the more likely bacterial epididymitis 4, 5. Standard albendazole dosing for enterobiasis is a single 400 mg dose, not twice weekly 6, 7.

Age-Stratified Empiric Antibiotic Treatment

For Men Under 35 Years (Sexually Transmitted Etiology)

Administer ceftriaxone 250 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2. This regimen targets C. trachomatis and N. gonorrhoeae, the predominant pathogens in younger sexually active men 1.

For Men Over 35 Years (Enteric Organism Etiology)

Prescribe ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2. These fluoroquinolones target Gram-negative enteric organisms (E. coli) that cause epididymitis in older men or those with urinary tract abnormalities 1, 2.

Alternative for Cephalosporin/Tetracycline Allergy

Use ofloxacin 300 mg orally twice daily for 10 days regardless of age 1.

Adjunctive Symptomatic Management

• Prescribe bed rest with scrotal elevation using rolled towel or supportive underwear until fever and local inflammation subside 1, 2
• Provide analgesics for pain control during the acute phase 1, 2
• Instruct complete sexual abstinence until both patient and partner(s) complete treatment and are symptom-free 2

Addressing the Dietary Trigger Pattern

The patient's report that spicy foods trigger burning while dairy does not suggests chemical irritation of inflamed urethral mucosa rather than a specific food allergy. This symptom pattern is consistent with urethritis accompanying epididymitis 1. The nocturnal predominance of dysuria may reflect concentrated urine irritating the inflamed urethra during sleep.

Partner Management and Sexual History

All sexual partners from the past 60 days must be evaluated and treated if testing confirms N. gonorrhoeae or C. trachomatis, even if asymptomatic 1, 3, 2. Failure to treat partners leads to reinfection and treatment failure.

Critical Follow-Up Timeline

3-Day Reassessment

If pain, swelling, or fever fail to improve within 3 days of initiating antibiotics, reevaluate both the diagnosis and therapy immediately 1, 2. This may indicate:

• Testicular torsion (requires emergency surgery) 1, 2
• Testicular abscess or infarction 1
• Incorrect pathogen coverage 1

Post-Treatment Evaluation

Swelling and tenderness persisting after completing the full 10-day antimicrobial course requires comprehensive urological evaluation to exclude tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2.

Management of Scrotal Pruritus

If Epididymitis Treatment Resolves Pruritus

The scrotal itching was likely secondary to epididymal inflammation and will resolve with appropriate antibiotics.

If Pruritus Persists After Epididymitis Treatment

Consider alternative diagnoses:

• Lichen sclerosus (requires potent topical corticosteroids) 1
• Contact dermatitis from the topical powders he has been applying 1
• True enterobiasis (requires single-dose mebendazole 100 mg or albendazole 400 mg, repeated after 2 weeks) 6, 8

Common Pitfalls to Avoid

• Never assume improvement means cure—the full 10-day antibiotic course must be completed to prevent chronic complications including infertility and chronic pain 1, 2
• Do not dismiss the possibility of testicular torsion based on presence of infection signs—both can coexist, and torsion requires emergency surgery 1, 3
• Stop the inappropriate twice-weekly albendazole immediately—this dosing has no evidence base and may cause unnecessary side effects 6
• Discontinue scrotal powders, as these may cause contact dermatitis and worsen pruritus 1