What is the likely diagnosis and appropriate workup and management for an 18‑year‑old male who has a tender suprascrotal area above the right testicle, orange cloudy urine with bilirubin and protein, and reports semen passage during a bowel movement?

Likely Diagnosis: Prostatitis or Seminal Vesiculitis

This 18-year-old male most likely has prostatitis or seminal vesiculitis, given the constellation of supratesticular tenderness, semen passage during bowel movements (spermatorrhea), and urinary findings without evidence of urethritis or testicular pathology. The key diagnostic steps are scrotal/transrectal ultrasound to evaluate the prostate and seminal vesicles, urine culture, and sexually transmitted infection testing, while the abnormal urinalysis findings (bilirubin, protein) require separate evaluation but are unlikely related to his genitourinary symptoms.

Critical Initial Assessment

Rule Out Surgical Emergencies First

• Testicular torsion must be excluded immediately in any young male with testicular/supratesticular pain, as surgical intervention within 6-8 hours is essential to prevent testicular loss 1
• The gradual onset of symptoms and lack of severe acute pain make torsion less likely, but if pain worsens acutely or becomes severe, obtain urgent scrotal Doppler ultrasound 1, 2
• Epididymitis typically presents with gradual pain onset and would show an enlarged, hyperemic epididymis on ultrasound, but the location "above the testicle" and spermatorrhea point elsewhere 2

Key Clinical Features Supporting Prostatitis/Seminal Vesiculitis

• Semen expelled during bowel movement (spermatorrhea) is pathognomonic for seminal vesicle or prostatic pathology, as these structures lie adjacent to the rectum 3
• Tenderness above the right testicle likely represents referred pain from the prostate/seminal vesicles or possibly the vas deferens
• Cloudy urine may indicate prostatic secretions or inflammation rather than infection, especially with negative nitrites and WBC esterase 4
• Weekly nocturnal emissions are normal for this age but may be relevant if there is prostatic congestion

Diagnostic Workup Algorithm

Immediate Studies

1. Scrotal ultrasound with Doppler to evaluate:

   • Testicular perfusion (rule out torsion if any concern) 1
   • Epididymis size and vascularity (rule out epididymitis) 2
   • Spermatic cord and vas deferens
   • Any masses or structural abnormalities 3

2. Transrectal ultrasound (TRUS) if scrotal ultrasound is unrevealing:

   • Evaluate prostate and seminal vesicles for enlargement, cysts, or inflammation 3
   • TRUS is specifically recommended for ejaculatory duct pathology 3

3. Urine culture (not just dipstick):

   • The negative nitrites and WBC esterase make bacterial infection less likely but don't exclude it 4
   • Culture is essential before treating presumed prostatitis 3

4. STI testing with nucleic acid amplification (NAAT):

   • Test for Neisseria gonorrhoeae and Chlamydia trachomatis 2, 5
   • Even without dysuria or urethral discharge, STIs can cause prostatitis in young males 5
   • First-void urine NAAT is appropriate 5

Address the Abnormal Urinalysis Findings

• Bilirubin 1+ and Protein 1+ are concerning and require separate evaluation:

  • These findings are not explained by genitourinary pathology 4
  • Orange urine with bilirubin suggests possible hepatobiliary disease or hemolysis 4
  • Obtain: liver function tests, complete blood count, and repeat urinalysis 4
  • Consider hepatitis screening given age and potential risk factors

• Trace ketones are likely from fasting/normal metabolism and not clinically significant 4

Important Pitfall: False-Positive Hematuria

• The urinalysis shows negative blood, but be aware that semen in urine can cause false-positive microhematuria on dipstick 6
• Given his spermatorrhea, any future positive blood on dipstick should be confirmed with microscopy before pursuing hematuria workup 7, 6

Management Based on Findings

If Prostatitis/Seminal Vesiculitis Confirmed

For patients <35 years, empiric treatment should cover STIs:

• Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg PO twice daily for 10 days 2
• This regimen covers both gonococcal and chlamydial infections 2, 5

Adjunctive measures:

• Bed rest, scrotal support, and analgesics until inflammation resolves 2
• Avoid prolonged sitting and sexual activity during acute phase
• Increase fluid intake

Follow-up within 3 days to ensure symptom improvement 2

If STI Testing Negative and Enteric Organisms Suspected

• Fluoroquinolone therapy: Levofloxacin 500 mg PO daily for 10 days 2
• Consider this if there are risk factors for enteric bacteria (anal intercourse, instrumentation)

If Imaging Shows Structural Abnormality

• Ejaculatory duct obstruction on TRUS requires urological consultation for possible transurethral resection 3
• Seminal vesicle cyst or abscess may require drainage 3
• Congenital anomalies (rare) would need specialized urological management 3

Red Flags Requiring Urgent Urological Referral

• Sudden worsening of pain suggesting torsion 1
• Fever, systemic symptoms suggesting abscess or severe infection 2
• Acute urinary retention 3
• Palpable mass on examination 3
• Persistent symptoms after 3 days of appropriate antibiotics 2

Common Pitfalls to Avoid

1. Do not dismiss supratesticular tenderness as benign without imaging—it may represent early epididymitis, torsion, or referred pain from prostate 1, 2

2. Do not rely solely on urinalysis dipstick for infection diagnosis—negative nitrites and WBC esterase do not exclude UTI or prostatitis, especially in young males 4

3. Do not ignore the bilirubin and protein in the UA—these require hepatic and renal evaluation independent of the genitourinary symptoms 4

4. Do not assume normal urinalysis rules out STI-related prostatitis—NAAT testing is essential in sexually active young males 2, 5

5. Do not delay imaging if clinical suspicion for torsion increases—even partial torsion can have normal Doppler in 30% of cases 1