A 5-year-old boy is brought to the physician for excessive weight gain. The mother reports that her son has been “chubby” since he was a toddler and that he has gained 10 kg (22 lbs) over the last year. During this period, he fractured his left arm twice from falling on the playground. He had cryptorchidism requiring orchiopexy at age 2. He is able to follow 1-step instructions and uses 2-word sentences. He is at the 5th percentile for height and 95th percentile for weight. Vital signs are within normal limits. Physical examination shows central obesity. There is mild esotropia and coarse, dry skin. In addition to calorie restriction, which of the following is the most appropriate next step in management of this patient?
Q2
A 30-year-old male presents with a testicular mass of unknown duration. The patient states he first noticed something unusual with his right testicle two weeks ago, but states he did not think it was urgent because it was not painful and believed it would resolve on its own. It has not changed since he first noticed the mass, and the patient still denies pain. On exam, the patient’s right testicle is non-tender, and a firm mass is felt. There is a negative transillumination test, and the mass is non-reducible. Which of the following is the best next step in management?
Q3
A 30-year-old man comes to the physician for his annual health maintenance examination. The patient has no particular health concerns. He has a history of bilateral cryptorchidism treated with orchidopexy at 8 months of age. This patient is at increased risk for which of the following?
Q4
A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
Q5
A couple brings their 1-year-old child to a medical office for a follow-up evaluation of his small, empty scrotum. The scrotum has been empty since birth and the physician asked them to follow up with a pediatrician. There are no other complaints. The immunization history is up to date and his growth and development have been excellent. On examination, he is a playful, active child with a left, non-reducible, non-tender inguinal mass, an empty and poorly rugated hemiscrotal sac, and a testis within the right hemiscrotal sac. Which of the following hormones would likely be deficient in this patient by puberty if the condition is left untreated?
Q6
A 16-year-old boy comes to the physician because of painless enlargement of his left testis for the past 2 weeks. The patient reports that the enlargement is worse in the evenings, especially after playing soccer. He has not had any trauma to the testes. There is no personal or family history of serious illness. Vital signs are within normal limits. Examination shows multiple cord-like structures above the left testes. The findings are more prominent while standing. The cord-like structures disappear in the supine position. The testes are normal on palpation. The patient is at greatest risk of developing which of the following complications?
Q7
A 22-year-old man is brought to the emergency department because of progressive left-sided scrotal pain for 4 hours. He describes the pain as throbbing in nature and 6 out of 10 in intensity. He has vomited once on the way to the hospital. He has had pain during urination for the past 4 days. He has been sexually active with 2 female partners over the past year and uses condoms inconsistently. His father was diagnosed with testicular cancer at the age of 51 years. He appears anxious. His temperature is 36.9°C (98.42°F), pulse is 94/min, and blood pressure is 124/78 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Examination shows a tender, swollen left testicle and an erythematous left hemiscrotum. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs. Which of the following is the most appropriate next step in management?
Q8
A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process?
Q9
An 11-year-old boy is brought to the emergency department with sudden and severe pain in the left scrotum that started 2 hours ago. He has vomited twice. He has no dysuria or frequency. There is no history of trauma to the testicles. The temperature is 37.7°C (99.9°F). The left scrotum is swollen, erythematous, and tender. The left testis is elevated and swollen with a transverse lie. The cremasteric reflex is absent. Ultrasonographic examination is currently pending. Which of the following is the most likely diagnosis?
Q10
A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
Undescended testis and orchiopexy US Medical PG Practice Questions and MCQs
Question 1: A 5-year-old boy is brought to the physician for excessive weight gain. The mother reports that her son has been “chubby” since he was a toddler and that he has gained 10 kg (22 lbs) over the last year. During this period, he fractured his left arm twice from falling on the playground. He had cryptorchidism requiring orchiopexy at age 2. He is able to follow 1-step instructions and uses 2-word sentences. He is at the 5th percentile for height and 95th percentile for weight. Vital signs are within normal limits. Physical examination shows central obesity. There is mild esotropia and coarse, dry skin. In addition to calorie restriction, which of the following is the most appropriate next step in management of this patient?
A. Levothyroxine
B. Fluoxetine
C. Laparoscopic gastric banding
D. Growth hormone therapy (Correct Answer)
E. Octreotide
Explanation: ***Growth hormone therapy***
- This patient's constellation of symptoms, including **obesity**, **short stature**, developmental delay (**1-step instructions, 2-word sentences at age 5**), **cryptorchidism**, and **bone fractures**, is highly suggestive of **Prader-Willi syndrome (PWS).**
- **Growth hormone therapy** is the most appropriate next step and is crucial for improving growth, body composition, muscle strength, and bone density in patients with Prader-Willi syndrome.
- Growth hormone therapy should be initiated in early childhood and has been shown to significantly improve height, lean body mass, and motor development in PWS patients.
- **Note:** While PWS is associated with hypogonadism, testosterone replacement is not initiated at age 5; it is typically reserved for adolescent males approaching puberty.
*Levothyroxine*
- While **coarse, dry skin** can suggest **hypothyroidism**, the overall clinical picture, including developmental delay, cryptorchidism, hyperphagia with obesity, and short stature, is classic for **Prader-Willi syndrome** rather than primary hypothyroidism.
- There are no other clear signs of hypothyroidism such as bradycardia, lethargy, or significant goiter.
*Fluoxetine*
- **Fluoxetine** is an SSRI that may be used for behavioral issues like hyperphagia, compulsive behaviors, or anxiety often seen in Prader-Willi syndrome, but it does **not address the underlying hormonal deficiencies** or growth failure.
- Behavioral management and psychiatric medications are adjunctive but secondary to addressing the growth and metabolic issues with hormone therapy.
*Laparoscopic gastric banding*
- This is a surgical option for severe, refractory obesity, but it is **not appropriate for a 5-year-old child**, especially not as a first-line treatment for obesity in Prader-Willi syndrome.
- The **underlying hormonal and metabolic issues** must be addressed first with growth hormone therapy and dietary management, and such invasive bariatric procedures carry significant risks and are not indicated in young children.
*Octreotide*
- **Octreotide** is a somatostatin analog used to inhibit growth hormone secretion in conditions like acromegaly or to manage symptoms of neuroendocrine tumors.
- In Prader-Willi syndrome, the issue is **growth hormone deficiency**, not excess, making octreotide contraindicated as it would worsen the growth failure.
Question 2: A 30-year-old male presents with a testicular mass of unknown duration. The patient states he first noticed something unusual with his right testicle two weeks ago, but states he did not think it was urgent because it was not painful and believed it would resolve on its own. It has not changed since he first noticed the mass, and the patient still denies pain. On exam, the patient’s right testicle is non-tender, and a firm mass is felt. There is a negative transillumination test, and the mass is non-reducible. Which of the following is the best next step in management?
A. MRI abdomen and pelvis
B. CT abdomen and pelvis
C. Testicular ultrasound (Correct Answer)
D. Send labs
E. Needle biopsy
Explanation: ***Testicular ultrasound***
- A **testicular ultrasound** is the diagnostic study of choice for evaluating a **scrotal mass** to determine if it is intratesticular or extratesticular, and to assess its characteristics (solid, cystic).
- The patient's presentation with a **painless, firm, non-transilluminating testicular mass** is highly suspicious for a **testicular tumor**, making immediate ultrasound essential to confirm the diagnosis.
*MRI abdomen and pelvis*
- While MRI can provide detailed anatomical information, it is typically performed for **staging** a confirmed testicular cancer, not as the initial diagnostic step.
- Its higher cost and longer imaging time make it less suitable for initial evaluation than ultrasound.
*CT abdomen and pelvis*
- CT scans are primarily used for **staging** testicular cancer, particularly to evaluate for **lymph node involvement** or distant metastases.
- It does not provide the resolution needed for precise characterization of an intratesticular mass and exposes the patient to **ionizing radiation**.
*Send labs*
- **Tumor markers** such as **alpha-fetoprotein (AFP)**, **beta-human chorionic gonadotropin (beta-hCG)**, and **lactate dehydrogenase (LDH)** are important for the diagnosis, staging, and monitoring of testicular cancer.
- However, blood tests alone cannot definitively diagnose a testicular mass or determine its nature; imaging is necessary.
*Needle biopsy*
- **Needle biopsy** is generally **contraindicated** for suspected testicular masses due to the risk of **tumor seeding** within the scrotum or along the biopsy tract.
- Diagnosis and tumor removal are typically achieved through an **inguinal orchiectomy** if malignancy is suspected.
Question 3: A 30-year-old man comes to the physician for his annual health maintenance examination. The patient has no particular health concerns. He has a history of bilateral cryptorchidism treated with orchidopexy at 8 months of age. This patient is at increased risk for which of the following?
A. Yolk sac tumor
B. Leydig cell tumor
C. Testicular lymphoma
D. Sertoli cell tumor
E. Teratocarcinoma (Correct Answer)
Explanation: ***Teratocarcinoma***
- Cryptorchidism is a known risk factor for the development of **testicular germ cell tumors**, which includes **teratocarcinoma**. Orchidopexy may make screening easier but does not eliminate the increased risk.
- Testicular germ cell tumors, such as teratocarcinoma, typically present in young men and can derive from **undifferentiated germ cells** that remain in the undescended testis.
*Yolk sac tumor*
- While a type of **germ cell tumor**, yolk sac tumors are more common in infants and young children, and less frequently the primary presentation in an adult with a history of treated cryptorchidism.
- In adults, yolk sac components can be part of a mixed germ cell tumor but are rarely the sole diagnosis in this age group in the context of cryptorchidism risk.
*Leydig cell tumor*
- Leydig cell tumors are **sex cord-stromal tumors**, not germ cell tumors, and are not significantly associated with a history of cryptorchidism.
- These tumors typically present with symptoms related to **hormone production**, such as gynecomastia or precocious puberty.
*Testicular lymphoma*
- Testicular lymphoma is the most common testicular tumor in men over **60 years old** and is not primarily linked to a history of cryptorchidism.
- This is a **hematopoietic neoplasm** that can originate in the testis or metastasize there, rather than a primary testicular tumor associated with developmental abnormalities.
*Sertoli cell tumor*
- Sertoli cell tumors are also **sex cord-stromal tumors** and are not strongly associated with cryptorchidism.
- They are generally rare and can sometimes produce hormones, leading to clinical manifestations like **gynecomastia**.
Question 4: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
A. Prostatitis
B. Seminoma
C. Testicular torsion
D. Sperm granuloma (Correct Answer)
E. Inguinal hernia
Explanation: **Sperm granuloma**
- A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction.
- This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue.
*Prostatitis*
- **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy.
- It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation.
*Seminoma*
- **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy.
- The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation.
*Testicular torsion*
- **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis.
- This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma.
*Inguinal hernia*
- An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal.
- Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.
Question 5: A couple brings their 1-year-old child to a medical office for a follow-up evaluation of his small, empty scrotum. The scrotum has been empty since birth and the physician asked them to follow up with a pediatrician. There are no other complaints. The immunization history is up to date and his growth and development have been excellent. On examination, he is a playful, active child with a left, non-reducible, non-tender inguinal mass, an empty and poorly rugated hemiscrotal sac, and a testis within the right hemiscrotal sac. Which of the following hormones would likely be deficient in this patient by puberty if the condition is left untreated?
A. LH
B. Testosterone (Correct Answer)
C. FSH
D. Inhibin
E. Prolactin
Explanation: ***Testosterone***
- **Testosterone** is produced by the **Leydig cells** in the testes. In untreated cryptorchidism, the elevated temperature in the inguinal canal causes progressive damage to both Sertoli cells and **Leydig cells** over time.
- By **puberty**, if left untreated for 11-13 years, the undescended testis will have significant irreversible Leydig cell dysfunction, leading to **reduced testosterone production**.
- While unilateral cryptorchidism may allow the contralateral descended testis to partially compensate, this compensation is often **incomplete during the high testosterone demands of puberty**, resulting in relative testosterone deficiency.
- This is the most clinically significant hormonal deficiency that develops with prolonged untreated cryptorchidism.
*LH*
- **Luteinizing hormone (LH)** is produced by the anterior pituitary and stimulates Leydig cells to produce testosterone. In cryptorchidism with resulting testosterone deficiency, LH levels would be **elevated** (not deficient) as a compensatory response.
- The pituitary responds normally to low testosterone with increased LH secretion via loss of negative feedback.
*Inhibin*
- **Inhibin** is produced by **Sertoli cells** in the seminiferous tubules. While cryptorchidism impairs Sertoli cell function and spermatogenesis, inhibin itself is not typically **deficient**.
- The primary consequence is **impaired spermatogenesis**, which leads to reduced negative feedback and **elevated FSH** levels, but inhibin levels may remain normal or only modestly reduced.
*FSH*
- **Follicle-stimulating hormone (FSH)** is produced by the anterior pituitary. In cryptorchidism, FSH is typically **elevated** (not deficient) due to impaired Sertoli cell function and loss of negative feedback from the seminiferous tubules.
- Elevated FSH is a marker of tubular dysfunction but is not itself deficient.
*Prolactin*
- **Prolactin** is produced by the anterior pituitary and primarily regulates lactation. It has no direct role in testicular function or the pathophysiology of cryptorchidism.
- There is no association between cryptorchidism and prolactin deficiency.
Question 6: A 16-year-old boy comes to the physician because of painless enlargement of his left testis for the past 2 weeks. The patient reports that the enlargement is worse in the evenings, especially after playing soccer. He has not had any trauma to the testes. There is no personal or family history of serious illness. Vital signs are within normal limits. Examination shows multiple cord-like structures above the left testes. The findings are more prominent while standing. The cord-like structures disappear in the supine position. The testes are normal on palpation. The patient is at greatest risk of developing which of the following complications?
A. Testicular torsion
B. Erectile dysfunction
C. Testicular tumor
D. Infertility (Correct Answer)
E. Bowel strangulation
Explanation: ***Infertility***
- The patient's presentation of a **painless left testicular enlargement** with **"bag of worms"** feeling that is more prominent when standing and disappears when supine is classic for a **varicocele**.
- Varicoceles increase scrotal temperature, which can impair spermatogenesis and lead to **reduced sperm count** and motility, thus increasing the risk of infertility.
*Testicular torsion*
- Testicular torsion typically presents with **sudden onset**, **severe testicular pain** and swelling, often associated with nausea and vomiting.
- The physical examination findings of a varicocele, specifically the **painless nature** and the **disappearance of swelling in the supine position**, rule out torsion.
*Erectile dysfunction*
- While hormonal imbalances can sometimes be associated with severe varicoceles due to Leydig cell dysfunction, **erectile dysfunction is not a direct or common complication** of varicocele in adolescents.
- Erectile dysfunction is more commonly related to psychological factors, vascular issues, or systemic diseases.
*Testicular tumor*
- Testicular tumors usually present as a **painless, firm mass** within the testis itself, which does not typically change with position.
- The description of **"cord-like structures above the testes"** that disappear in the supine position is inconsistent with a solid testicular mass.
*Bowel strangulation*
- Bowel strangulation involves compromised blood supply to a segment of the bowel, often within a hernia, leading to severe abdominal pain, nausea, and vomiting.
- The symptoms described are localized to the scrotum and are not indicative of an abdominal emergency like bowel strangulation or an incarcerated hernia.
Question 7: A 22-year-old man is brought to the emergency department because of progressive left-sided scrotal pain for 4 hours. He describes the pain as throbbing in nature and 6 out of 10 in intensity. He has vomited once on the way to the hospital. He has had pain during urination for the past 4 days. He has been sexually active with 2 female partners over the past year and uses condoms inconsistently. His father was diagnosed with testicular cancer at the age of 51 years. He appears anxious. His temperature is 36.9°C (98.42°F), pulse is 94/min, and blood pressure is 124/78 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Examination shows a tender, swollen left testicle and an erythematous left hemiscrotum. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs. Which of the following is the most appropriate next step in management?
A. Scrotal ultrasonography (Correct Answer)
B. CT scan of the abdomen and pelvis
C. Surgical exploration
D. Measurement of serum mumps IgG titer
E. Measurement of serum α-fetoprotein level
Explanation: ***Scrotal ultrasonography***
- A definitive diagnosis of **epididymitis**, **orchitis**, or **testicular torsion** requires imaging, which can confirm blood flow to the testis.
- Given the symptoms of testicular pain, tenderness, and inflammation in a sexually active young man, **epididymitis** is highly suspected, but **testicular torsion** must be ruled out as it's a surgical emergency.
*CT scan of the abdomen and pelvis*
- This imaging modality is **not indicated** for the initial evaluation of acute scrotal pain.
- While it can identify other intra-abdominal pathology, it does **not provide sufficient detail** of the scrotal contents or blood flow.
*Surgical exploration*
- **Surgical exploration** is the treatment for **testicular torsion**, but it should only be performed after a clinical or ultrasound diagnosis of testicular torsion is made.
- Doing an immediate surgical exploration without imaging may result in unnecessary surgery if the patient has epididymitis.
*Measurement of serum mumps IgG titer*
- While **mumps orchitis** can cause testicular pain, this patient has symptoms more consistent with an infection related to sexual activity or a potential torsion.
- Measuring mumps titers would **delay diagnosis** and management for more urgent conditions like testicular torsion.
*Measurement of serum α-fetoprotein level*
- **Alpha-fetoprotein (AFP)** is a tumor marker primarily used for the diagnosis and monitoring of **testicular cancer**.
- This patient presents with acute pain and inflammatory signs, which are **not typical for testicular cancer**; AFP measurement is not indicated in the acute setting.
Question 8: A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process?
A. Diaphragmatic hernia
B. Femoral hernia
C. Testicular torsion
D. Hydrocele (Correct Answer)
E. Varicocele
Explanation: ***Hydrocele***
- The patient's symptoms (intermittent groin bulge with crying/straining) are classic for an **indirect inguinal hernia**, which, like a hydrocele, results from an **incompletely obliterated processus vaginalis**.
- A **hydrocele** involves the accumulation of **serous fluid** within the persistent processus vaginalis, as opposed to abdominal contents in a hernia.
*Diaphragmatic hernia*
- This condition involves the protrusion of abdominal contents into the chest cavity through a defect in the **diaphragm**.
- It is unrelated to the obliteration of the processus vaginalis but rather to **diaphragmatic development**.
*Femoral hernia*
- A femoral hernia involves protrusion through the **femoral canal**, inferior to the inguinal ligament.
- It does not involve the processus vaginalis and is more common in **multiparous women**.
*Testicular torsion*
- This condition is a surgical emergency caused by the **twisting of the spermatic cord**, compromising blood supply to the testis.
- It is not related to the processus vaginalis but often involves an inadequately fixed testis (bell-clapper deformity).
*Varicocele*
- A varicocele is an abnormal dilation of the **pampiniform venous plexus** within the spermatic cord.
- It is caused by incompetent valves in the testicular veins and not by a patent processus vaginalis.
Question 9: An 11-year-old boy is brought to the emergency department with sudden and severe pain in the left scrotum that started 2 hours ago. He has vomited twice. He has no dysuria or frequency. There is no history of trauma to the testicles. The temperature is 37.7°C (99.9°F). The left scrotum is swollen, erythematous, and tender. The left testis is elevated and swollen with a transverse lie. The cremasteric reflex is absent. Ultrasonographic examination is currently pending. Which of the following is the most likely diagnosis?
A. Testicular torsion (Correct Answer)
B. Mumps orchitis
C. Spermatocele
D. Epididymitis
E. Germ cell tumor
Explanation: ***Testicular torsion***
- The sudden onset of **severe scrotal pain** with associated **vomiting**, an **elevated testis**, **transverse lie**, and an **absent cremasteric reflex** are classic signs of testicular torsion.
- This condition is a surgical emergency requiring prompt diagnosis and intervention to prevent testicular ischemia and necrosis.
*Mumps orchitis*
- This typically occurs in post-pubertal males with a history of **mumps infection** and presents with testicular swelling and pain, but usually after the onset of parotitis.
- While it can cause pain and swelling, the **acute onset** and specific findings like absent cremasteric reflex and transverse lie are less characteristic.
*Spermatocele*
- A spermatocele is a **painless, fluid-filled cyst** originating from the epididymis, typically found on the superior aspect of the testis.
- It does not present with acute, severe pain, vomiting, or signs of testicular compromise.
*Epididymitis*
- Epididymitis commonly presents with **gradual onset** of scrotal pain, swelling, and tenderness, often associated with a urinary tract infection or sexually transmitted infection.
- The cremasteric reflex is typically **preserved**, and elevation of the testicle (Prehn's sign) may relieve pain.
*Germ cell tumor*
- Testicular tumors usually present as a **painless lump** or mass in the testis, though some may cause a dull ache or sensation of heaviness.
- Acute severe pain, vomiting, and findings like an absent cremasteric reflex are not typical presentations of a testicular tumor.
Question 10: A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
A. Traumatic urethral injury
B. Seminoma
C. Appendicitis
D. Epididymitis
E. Testicular torsion (Correct Answer)
Explanation: ***Testicular torsion***
- The sudden onset of **unilateral scrotal pain** in an adolescent, accompanied by an **elevated testicle** with a **horizontal lie**, is highly suggestive of testicular torsion. The absence of scrotal swelling or discoloration in the early stages is also consistent.
- Testicular torsion is a **surgical emergency** requiring prompt intervention to preserve testicular viability.
*Traumatic urethral injury*
- This would typically present with **dysuria**, **hematuria**, inability to void, and potentially **blood at the urethral meatus**, none of which are described.
- A traumatic urethral injury often results from falls, straddle injuries, or pelvic fractures, not typically from playing football without direct trauma to the perineum.
*Seminoma*
- Seminoma is a type of **testicular cancer** that typically presents as a **painless testicular mass**.
- It would not cause sudden, acute abdominal pain and would not manifest with an acutely elevated testicle and horizontal lie.
*Appendicitis*
- Although appendicitis can cause abdominal pain, the **non-tender abdomen** on examination and the specific findings on **testicular examination** (elevated testicle, horizontal lie) make appendicitis unlikely.
- Appendicitis pain typically localizes to the right lower quadrant, often associated with fever, nausea, and vomiting.
*Epididymitis*
- Epididymitis causes **scrotal pain** and **swelling**, often with fever and **dysuria**, usually developing over days, not hours.
- It is often associated with the **Prehn's sign** (pain relief with elevation of the testicle), which is usually absent or negative in torsion. The patient's sexual history might suggest an STI, but the acute presentation and examination findings point away from epididymitis.
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