---

Your Symptoms - What They Suggest

---

Most Likely Diagnoses

1. Urethritis from STI (Most Likely - Primary Diagnosis)

"Urethritis from STI presents with dysuria, penile discharge, pain with intercourse, and testicular pain."

"C. trachomatis and N. gonorrhoeae are the most common causes of epididymitis in male patients younger than 35 years of age. Epididymitis presents as unilateral testicular pain and swelling accompanied by dysuria."

2. Acute Epididymo-Orchitis (Secondary/Related)

"In young men [epididymo-orchitis] usually arises secondary to a sexually transmitted genital infection."

3. Acute Prostatitis (Possible)

---

⚠️ Must Rule Out

• Testicular Torsion - if pain returns suddenly and severely, this is a surgical emergency. The fact that pain has partially resolved is slightly reassuring, but if pain returns suddenly and acutely, go to the emergency department immediately.
• Testicular Tumor - rarely presents with pain, but must be considered if there is any mass or hardness.

---

Investigations to Get

1. Urine NAAT/PCR for Chlamydia and Gonorrhea (most important)
2. Urinalysis (midstream urine) - look for WBCs, nitrites
3. Urine culture - if bacterial urinary infection suspected
4. Scrotal ultrasound - to assess epididymis and testes, and rule out torsion or abscess
5. Urethral swab (if discharge present)
6. STI screen - HIV, syphilis, hepatitis

---

Treatment

If STI (Chlamydia/Gonorrhea) Most Likely:

Supportive Treatment:

• NSAIDs (e.g., ibuprofen 400 mg three times daily with food) for pain and inflammation
• Scrotal support/elevation - helps reduce pain
• Rest, avoid strenuous activity

Additional (if enteric organisms or anal sex history):

• Levofloxacin 500 mg orally once daily for 10 days, OR
• Ofloxacin 300 mg orally twice daily for 10 days

---

Key Advice

1. See a doctor today - do not delay. Even though the testicular pain has reduced, you need proper testing and treatment to prevent complications like infertility or spread of infection.
2. Inform and treat sexual partner(s) - STIs require partner notification and simultaneous treatment.
3. Abstain from unprotected sex until both you and your partner have completed treatment.
4. Do NOT take antibiotics without prescription - wrong antibiotic or incomplete course can cause antibiotic resistance and complications.
5. If testicular pain returns suddenly, or you develop fever/chills/vomiting - go to emergency immediately (rule out torsion or abscess).

---

Disclaimer: This is educational information only, not a substitute for a doctor's consultation. Please visit a urologist, general practitioner, or sexual health clinic for proper examination, testing, and treatment.

• Bailey & Love's Short Practice of Surgery, 28th Ed.
• Tintinalli's Emergency Medicine, Comprehensive Study Guide
• Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.
• Fitzpatrick's Dermatology, Vol. 1-2

---

Is It a UTI? - Probably Not the Primary Cause

UTI in Males is Uncommon

---

How to Tell the Difference

---

What About Both?

---

Bottom Line

• Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.
• Tintinalli's Emergency Medicine

---

No Discharge - What Does It Mean?

"The absence of visible discharge does not exclude the diagnosis of urethritis."

"Urethritis can be associated with dysuria or mucopurulent discharge or can be completely asymptomatic."

---

The Likely Culprit: NGU (Non-Gonococcal Urethritis)

• Mild burning/irritation during urination
• Little or no visible discharge (or only slight clear fluid in the morning)
• Urethral itching or discomfort

---

Revised Probability With No Discharge

---

How to Diagnose Without Discharge

1. Urine PCR/NAAT for Chlamydia and Gonorrhea (most reliable test - done on first-void urine)
2. Urinalysis - 10 or more white blood cells (WBCs) per high-power field
3. Positive leukocyte esterase on first-void urine dipstick

---

Key Takeaway

• Rosen's Emergency Medicine
• Swanson's Family Medicine Review

---

Treatment Plan for NGU / Chlamydia Urethritis (Pakistan)

Option 1 - Doxycycline (FIRST CHOICE - current guideline preference)

---

Option 2 - Azithromycin (If you cannot complete 7 days or prefer single dose)

---

Option 3 - If Gonorrhea Also Suspected (cover both organisms)

---

Option 4 - For Pain/Inflammation (Supportive)

---

Practical Steps in Pakistan

1. Go to a pharmacy - Doxin (Doxycycline) and Azomax/Zithromax (Azithromycin) are available over the counter at most pharmacies in Pakistan without prescription.
2. Get Doxin 100mg - ask for a full strip (10 tablets) - take 1 tablet morning, 1 at night for 7 days.
3. Add Brufen 400mg for pain relief as needed.
4. See a doctor if symptoms do not improve in 3-4 days, pain returns in testis, or you develop fever - you may need the ceftriaxone injection.
5. Tell your partner - they must be treated at the same time, otherwise you will re-infect each other.

---

⚠️ Important Warnings

• Do not stop after 2-3 days just because you feel better - complete the full 7 days
• Do not take doxycycline if you are under 12 years old or pregnant
• Avoid sun exposure while on doxycycline (causes photosensitivity)
• No alcohol with metronidazole if prescribed

Disclaimer: This is for educational guidance. A doctor's consultation and proper testing (urine PCR) is strongly recommended for accurate diagnosis and treatment.

---

🇵🇰 Complete Prescription - Pakistan Brand Names

---

DRUG 1 - Ceftriaxone Injection (for Gonorrhea)

---

DRUG 2 - Doxycycline Tablets (for Chlamydia + epididymitis)

---

DRUG 3 - Ibuprofen (for pain + swelling)

---

DRUG 4 - Scrotal Support

• Wear tight, supportive underwear (not loose boxers) for the next 10 days - this reduces testicular pain and swelling significantly.

---

Complete 10-Day Prescription Summary

Rx:

1. Inj. Rocephin (Ceftriaxone) 500mg IM  
   → STAT (once only, Day 1)

2. Tab. Doxin (Doxycycline) 100mg  
   → 1 tablet TWICE daily (morning + night) × 10 days
   → Take with food and water

3. Tab. Brufen (Ibuprofen) 400mg  
   → 1 tablet THREE times daily × 5-7 days
   → Take with food only

---

⚠️ Critical Instructions

---

🚨 Go to Hospital Immediately If:

• Testicular pain returns suddenly and severely (could be torsion)
• You develop fever above 38.5°C
• Testis becomes very swollen or red
• No improvement after 3-4 days of treatment

---

Disclaimer: This is educational guidance based on standard medical guidelines. A proper doctor's examination, urethral swab, and urine PCR test are strongly recommended before starting antibiotics. Please consult a doctor or urologist for confirmation.

• Harrison's Principles of Internal Medicine, 22nd Ed. (2025)
• Tintinalli's Emergency Medicine

---

Not All Cases Are STIs - Other Causes Are Very Real

"Epididymitis is typically caused by sexually transmitted pathogens OR by organisms known to cause urinary tract infection."

---

Non-STI Causes That Fit Your Symptoms Perfectly

1. Acute Bacterial Prostatitis (Very Likely)

• The prostate gland gets infected by normal gut bacteria (E. coli, Klebsiella)
• Causes: burning urination, white/cloudy discharge, pelvic discomfort, sometimes testicular pain
• No sexual contact needed - bacteria from your own bowel travel to the prostate
• Common in young and middle-aged men
• Triggered by: dehydration, holding urine too long, constipation, sitting for long hours, cycling

2. UTI with Prostatitis (Complicated UTI in Males)

• Urinary bacteria spread from bladder to prostate/epididymis
• Same bacteria that cause UTI in women (E. coli) can infect the male urinary tract
• Causes white cells and mild discharge from urethra

3. Epididymo-Orchitis from UTI Bacteria

• Gram-negative enteric bacteria (E. coli, Proteus) travel from urethra upward to the epididymis and testis
• Does not require sexual contact at all
• More common with: urinary tract structural problems, dehydration, kidney stones

4. Non-Specific Urethritis

• Inflammation of the urethra from irritants - tight clothing, chemical irritation, spicy food, concentrated urine from not drinking enough water

---

What Changes in Your Treatment?

For Non-STI Bacterial Infection (Prostatitis / UTI-origin):

Rx (Pakistan Brands):

1. Tab. Ciprofloxacin (Cipro / Cifran / Ciprowin) 500mg
   → 1 tablet TWICE daily × 14 days
   (fluoroquinolones penetrate the prostate very well)

   OR

   Tab. Levofloxacin (Levaquin / Levotas / Lovomax) 500mg
   → 1 tablet ONCE daily × 10-14 days

2. Tab. Brufen (Ibuprofen) 400mg
   → 1 tablet THREE times daily × 5 days
   → Take with food

3. Drink at least 2.5-3 litres of water daily

---

Which Doctor to See

• Urologist - best specialist for this
• OR any general doctor / family physician

---

What Tests to Ask For

---

Bottom Line

Disclaimer: Please see a doctor for proper examination. This is educational guidance only.

• Smith & Tanagho's General Urology, 19th Ed.
• Textbook of Family Medicine, 9th Ed.

---

How This Happens - Step by Step

The Basic Problem: Bacteria Enter and Travel Up

Bacteria enter urethra
        ↓
Urethra gets inflamed → burning urine, white discharge
        ↓
Travel up to PROSTATE → testicular/pelvic pain
        ↓
Travel further to EPIDIDYMIS/TESTIS → testicular pain and swelling

---

What Triggers This in Young Men?

Common Everyday Triggers:

---

Why Did Your Testis Hurt First?

Prostate infection → inflammation travels backward through vas deferens → epididymis pain → testis pain

---

Why the White Discharge?

---

In Short - Most Likely Reason in Your Case

Bacteria from your own body (like E. coli) found a way into your urethra - possibly due to dehydration, prolonged sitting, constipation, or reduced immunity - and traveled upward infecting the urethra, prostate and temporarily irritating the testicular area.

---

How to Prevent It Coming Back

1. Drink 8-10 glasses of water every day - most important step
2. Never hold urine for more than 3-4 hours
3. Eat more fruits, vegetables, fibre - prevent constipation
4. Avoid excessive tea, coffee, and spicy food during and after treatment
5. Take warm baths - reduces pelvic muscle tension
6. Do not sit for more than 1-2 hours without a short walk break

---

Campbell-Walsh-Wein Urology | Textbook of Family Medicine, 9th Ed.

---

Ciprofloxacin (Cifran / Cipro) - Food Timing

✅ Can be taken WITH or WITHOUT food

• Food does not significantly affect its absorption
• However, taking it with a light meal is better to reduce stomach upset (nausea, acidity)
• Do NOT take with milk, yogurt, or dairy alone - calcium blocks absorption
• Do NOT take with antacids (like Gaviscon, Maalox, Mylanta) - they reduce absorption severely. Keep a 2-hour gap between ciprofloxacin and any antacid

Best Practice:

Take Ciprofloxacin after a light meal (not dairy), with a full glass of water

---

Cranmax (Cranberry Extract) - Food Timing

✅ Take WITH food or after a meal

• Cranberry supplements can cause stomach upset, nausea, or acidity if taken on empty stomach
• Taking after food reduces this irritation
• No major interaction with ciprofloxacin - they are safe to take together

Best Practice:

Take Cranmax after a meal

---

Important: Cranberry + Ciprofloxacin Interaction

---

Simple Daily Schedule

---

⚠️ Avoid with Ciprofloxacin:

• Milk, yogurt, cheese (within 2 hours)
• Antacids / Gaviscon / calcium tablets (2-hour gap)
• Tea / coffee immediately after (reduces absorption slightly)
• Alcohol

---

ACUTE APPENDICITIS - Complete Clinical Guide

---

1. Definition & Epidemiology

• Accounts for 17% of all emergency abdominal pain presentations
• Lifetime risk: 8.6% in males, 6.7% in females
• Peak age: teens and early twenties
• More common in males (M:F = 3:2 at age 25)
• Rare under 2 years of age and after middle age

---

2. Aetiology (Causes)

---

3. Pathophysiology (How It Progresses)

Luminal obstruction
        ↓
↑ Intraluminal pressure + mucus secretion
        ↓
Oedema + mucosal ulceration → Bacterial translocation to submucosa
        ↓
Venous obstruction → Ischaemia of appendix wall
        ↓
Bacterial invasion through wall → ACUTE APPENDICITIS
        ↓
Ischaemic necrosis → GANGRENOUS APPENDICITIS
        ↓
Perforation → PERITONITIS or APPENDIX ABSCESS

---

4. History (Symptoms)

Classic Symptom Sequence (present in ~50% of cases):

• Vague, colicky, periumbilical pain (around the navel)
• Poorly localised, intermittent
• Similar to mild small bowel colic but less intense
• Due to appendiceal distension stimulating visceral nerve fibres

• Anorexia (loss of appetite) - very constant feature, especially in children
• Nausea and 1-2 episodes of vomiting (vomiting follows pain onset - Murphy's rule: "pain before vomiting")
• Low-grade fever (37.2-37.7°C)

• Pain migrates to the Right Iliac Fossa (RIF) - lower right abdomen
• Becomes constant, sharp, well-localised
• Worsened by coughing, movement, or deep breathing
• Patient prefers to lie still

Key History Points to Ask:

---

5. Examination (Signs)

General Inspection:

• Patient looks unwell, flushed
• Lies still - movement worsens pain
• May walk bent forward holding right side
• Low-grade pyrexia (37.2-37.7°C); pulse 80-90 bpm
• In 20% of cases, NO fever in early stages

Abdominal Examination:

• Limited respiratory movement in the lower abdomen
• No visible distension (unless perforated)
• Ask patient to point to where pain began, then where it moved (Pointing Sign)

• Tenderness over McBurney's point on gentle percussion
• Elicits rebound tenderness without forceful release

• Tenderness in right side of rectovesical pouch
• Mandatory in every patient with acute lower abdominal pain
• Especially important when appendix is pelvic in position

---

6. Special Positions of the Appendix & Their Presentation

---

7. Investigations

Routine (all patients):

Imaging:

---

8. Alvarado Score (MANTRELS) - Clinical Decision Tool

---

9. Differential Diagnosis

---

10. Complications

---

11. Treatment

Surgical (Standard):

• Appendicectomy (appendix removal) - definitive treatment
• Laparoscopic approach - preferred (faster recovery, less wound infection)
• Open (McBurney's incision) - used when laparoscopy unavailable or perforated

Pre-operative:

• IV fluids, NBM (nil by mouth)
• IV antibiotics: Metronidazole + 3rd generation cephalosporin (e.g. Cefotaxime)
• Analgesia (do NOT withhold - does NOT mask signs)

Non-operative (selected uncomplicated cases):

• IV antibiotics only (Metronidazole + Cephalosporin)
• Successful in ~85% initially
• 25-33% will need surgery within 1 year

Appendix Mass (Ochsner-Sherren Regime):

• Conservative - IV antibiotics, bowel rest, observe
• Mark mass limits on skin with pen
• Measure pulse + temperature 4-hourly
• Operate if: rising pulse, spreading pain, enlarging mass, peritonitis signs

---

12. Summary - Classic Presentation at a Glance

Young patient (teens-30s)
↓
Sudden periumbilical colicky pain
↓
Anorexia + nausea + 1-2 vomits (pain comes FIRST)
↓
Pain shifts to RIF after 6-8 hours - becomes constant
↓
Low grade fever (37.2-37.7°C)
↓
Examination: RIF tenderness, guarding, rebound, Rovsing's +ve
↓
WBC elevated with neutrophilia
↓
Alvarado score ≥7 → Surgical referral → Appendicectomy

---

Bailey & Love's Short Practice of Surgery, 28th Ed. | Sleisenger & Fordtran's Gastrointestinal and Liver Disease | Rosen's Emergency Medicine

---

Scrotal Swellings - Complete Guide

---

1. HYDROCELE

Definition

Types

History

• Painless scrotal swelling
• Gradual onset
• May increase in size during the day (communicating type)
• No fever, no nausea

Examination

⚠️ Key Warning

Treatment

---

2. VARICOCELE

Definition

Key Facts

• Occurs in 15% of all males; found in 35-40% of infertile males
• 90% left-sided - because left spermatic vein drains at a 90° angle into the left renal vein (higher resistance)
• Right-sided varicocele = rare = suspect retroperitoneal mass / IVC obstruction

History

• Usually asymptomatic
• Dull, dragging ache or heaviness in scrotum, worse after standing/exercise
• May cause subfertility/infertility
• No acute severe pain

Examination

Grading (Clinical)

Treatment

---

3. INGUINAL HERNIA

Definition

Types

History

• Intermittent bulge in groin or scrotum, appears on straining/coughing/standing
• Usually painless when reducible
• Painful if incarcerated (stuck) or strangulated (blood cut off) - EMERGENCY
• Associated vomiting and abdominal pain if bowel obstructed

Examination

Complications

• Incarceration - hernia stuck, cannot reduce - tender, firm swelling
• Strangulation - blood supply cut off → bowel gangrene - surgical emergency

Treatment

---

4. TESTICULAR TORSION

Definition

Pathophysiology

• Bell-clapper deformity - testis hangs freely inside the tunica like a clapper in a bell → rotates freely → twists → venous obstruction → arterial ischemia → infarction if not reversed within 6 hours

History

• Sudden, severe, unilateral testicular pain - often wakes patient from sleep
• Onset: within hours (most acute presentation of all scrotal conditions)
• Nausea and vomiting almost always present
• May radiate to abdomen (can be mistaken for appendicitis!)
• Age: bimodal - neonates AND puberty (12-18 years)
• No fever, no dysuria (unlike epididymitis)

Examination

Time and Salvage Rate

Treatment

---

MASTER DIFFERENTIATION TABLE

---

Quick Memory Trick

---

Rosen's Emergency Medicine | Textbook of Family Medicine, 9th Ed. | Campbell-Walsh-Wein Urology