discussion response

Respond to below casestudy

1. Describe how culture might impact the diagnosis, management, and follow-up care of patients with the genitourinary disorders your colleagues discussed.

Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives

Mark, a 15-year-old male presents with a complaint of acute left scrotal pain with nausea that began 6 hours ago after a wrestling match. The pain is a dull ache and has gradually worsened to where he can no longer stand without doubling over. He is afebrile. A negative exam except for elevation of the left testicle, diffuse scrotal edema, and the presence of a "blue dot sign." The LOCATES have been answered some additional questions to ask are:

!). Has this ever happened before? 2). What are his allergies? What medications does he take?  3). Has anyone else in the family had this happened before? 4). Has he been exposed to TB? 5). Is he sexually active, if so, does he use condoms? Has he been checked for an STI or a history of an STI? 6). Any pain or burning during urination, any urgency or frequency? 7). Any discharge from the penis? Any pain in the lower abdomen? Noticed any blood in his semen?  8) Has he taken anything for pain? Is he up to date on vaccines? What makes it better or worse?

I would perform a U/A, CBC, check for STIs, and an ultrasound of the scrotum and the abdomen. 

Differential diagnoses:

Testicular torsion: is an emergent medical condition and restoration of blood supply in the involved testis must be achieved as soon as possible after onset to salvage testicular tissue. It initially obstructs venous return and the spermatic cord shortens as it twists, whereby the testis appears to be situated higher within the scrotum (Fijuta et al., 2017). Testicular torsion may happen during exercise, sitting, standing, physical exertion, trauma, or sleeping (Urology Care Foundation, n.d.). Generally, there is a 6-hour window following a testicular torsion before significant ischemic damage and alteration in spermatic morphology and formation occurs. It can occur at any age but is most common in adolescence and is uncommon before the age of 10. The left side is twice as likely to be involved because of the longer spermatic cord. S/S is a sudden, severe onset of unilateral scrotal pain, often with nausea or vomiting, edema, redness, tenderness, and warmth of the scrotum (Burns et al., 2017). A Prehn sign (elevating the affected testicle to help relieve pain) can be done but will not relieve the pain (Dains, Baumann, & Scheibel, 2016). Dx: A U/A will appear normal. A doppler ultrasound, a testicular flow scan can be considered if doppler is normal and time allows (Burns et al., 2017). Treatment: immediate referral to surgery. An occasional manual reduction can be done bur surgery must follow within 6-12 hours to prevent retortion, infertility, and an abscess and atrophy. If torsion persists for more than 24 hours loss of the testis can result (Burns et al., 2017).

Torsion of appendix testis: is a Mullerian duct remnant on the superior aspect of the testicle. A small piece of tissue above a testicle. It does not have a function in the body. When torsion occurs, a hard, tender nodule may be palpable on the upper pole of the testicle, and a blue discoloration referred to as the "blue dot sign" may be visible. Scrotal edema develops rapidly and often obscures physical examination findings (Fujita, Tambo, Okegawa, Higasihara, & Nutahara, 2017). It is more common in preteens. S/S includes pain in one testicle, swelling, and redness of the scrotum, a hard lump at the top of the scrotum, and the common "blue dot sign"It shows the twist is in the appendage, not the testicle. Dx: urine to check for infection and a Doppler ultrasonography or a testicular flow scan. Treatment includes rest, raising the area to ease swelling and OTC pain relievers. NSAIDs and Tylenol can be alternated every 6 hours. The inflammation usually resolves in 3-5 days. It may be a response to hormonal stimulation (St. Luke's Health System, n.d.)

Epididymitis: an inflammation of the epididymis that is painful and acute and is usually caused by an STI like Neisseria gonorrhoeae or Chlamydia trachomatis in sexually active adolescents, with an infection present in the urethra or bladder. It can be caused by a viral, coliform bacterial, or tubercular infection, chemical irritation, or dysfunctional voiding.S/S include pain, swelling, redness, warmth, and tenderness to the affected area, unilateral, discharge (purulent in gonorrhea, scant and watery in chlamydia), pain or discomfort in the lower abdomen, blood in semen. Dx: an STI screening, ultrasound with color doppler, U/A, CBC to check for increased WBCs, urethral culture and Gram stain, HIV test, a physical exam with the testis in normal position, positive Prehn's sign (pain is relieved with the elevation of the scrotum). A rectal exam will yield prostate tenderness. Treatment: rest, supporting the scrotum with an athletic strap, ice packs, pain medication, sitz baths, antibiotics, if STI, the sexual partner must be treated. Antibiotics first line: Ceftriaxone 250 mg IM X1 plus doxycycline 100 mg BID for 10 days, Ofloxacin 300 mg BID for 10 days or Levofloxacin 500 mg daily for 10 days. Pain and edema usually resolve within 1 week. Referral to a urologist is indicated if a solitary testicle is involved, if a prompt response to treatment does not occur, or if a question about the diagnosis remains. Treatment of sexual partner(s) is needed if caused by an STI. Avoid heavy lifting and sexual intercourse until the infection has cleared. Be sure to take all of the antibiotics, follow up if needed if no improvements, and after antibiotics to ensure that no palpable mass remains (Burns et al, 2017).

He should have had Varicella, Dtap, MMR, IPV. At age 11 or 12, HPV 2 doses at 6 months apart can be given, 1st dose of Meningococcal and Tdap. HPV will be given in 3 shots over a 6 month period for those who started at age 15. His next visit should be at age 16 with his second dose of Meningococcal and start the Men B  (2 doses). An annual flu vaccine is advised (CDC, 2019). 

He should practice abstinence, if not, use condoms. Avoid drugs, cigarettes, and alcohol. Do not text and drive, limit TV, computer, and cell phone time. Wear seat belts in all vehicles. Try to eat a healthy diet, drink lots of water, exercise, and get at least 8 hours of sleep. Follow up with a PCP when needed and yearly and see a dentist every 6 months. Parents should be role models and set rules on TV time, being active, and eating healthy. Parents should lock gun cabinets, liquor cabinets and prescription medications (Hagan, Shaw, & Duncan, 2017).

Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B., Blosser, C.G., & Garzon, D.L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, MO: Elsevier. 

CDC. (2019). Immunization schedule. Retrieved from www.cdc.gov.

Dains, J.E., Baumann, L.C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care. (5th ed). St. Louis, MO: Elsevier.

Fujita, N., Tambo, M., Okegawa, T., Higashihara, E., & Nutahara, K. (2017). Distinguishing testicular torsion from torsion of the appendix testis by clinical features and signs in patients with acute scrotum. Research and Reports in Urology, 9(23): 169-174. Retrieved from www.ncbi.nlm.nih.gov.

Hagan, J.F., Jr., Shaw, J.S., Duncan, P.M. (Eds.). (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

St. Luke's Health System. (n.d.). Testicular Appendage Torsion. Retrieved from www.saintlukeskc.org.

Urology Care Foundation. (n.d.). What is Testicular Torsion? Retrieved from www.urologyhealth.org.