Cases/Sexual Health

Remote Triage of the Acute Scrotum — Free SCA Practice Case

Remote Triage of the Acute Scrotum

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Liam Davis

Age

25 years

Consultation Type

Telephone

Age

25 (DOB: 12/08/2000)

Situation

Telephone Consultation (Urgent Triage).

Reason for Encounter

"Patient booked an urgent same-day phone call. Reception note simply states: 'Pain and swelling in left testicle.'"

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.

Recent Notes

●Has not been seen in the practice for 3 years.

Patient Script

For the friend playing the patient role

Character Overview: You are Liam, a 25-year-old graphic designer. You are incredibly embarrassed to be discussing this over the phone. You have been putting off speaking to a doctor for three days, hoping it would resolve, but the pain is now unbearable. Your left testicle has swollen to twice the size of the right. It feels heavy, warm, and throbs constantly. The pain radiates up into your left groin. You also noticed a slight burning sensation when you peed this morning, and yesterday you saw a tiny drop of yellowish discharge in your underwear. You recently ended a long-term relationship. Two months ago, you had unprotected vaginal sex with a new female partner. You have never had an STI before; you are currently terrified that you have testicular cancer. You will not volunteer the urethral discharge, the dysuria, or the unprotected sex unless the doctor actively conducts a structured urological and sexual history. You are defensive and closed-off initially due to embarrassment.

Consultation Flow & Responses:

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The Opening:
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If the doctor asks an open question: "Hi. Thanks for calling. It's my... well, my left testicle. It's really swollen and the pain is getting pretty bad. I've been taking ibuprofen but it's doing nothing."
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Data Gathering (The Layers):
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Layer 1: The Remote Torsion Screen (The Surgical Emergency):
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If asked about the onset of pain (Sudden vs. Gradual): "It started about three days ago. Just an ache at first, but it's slowly gotten worse and worse. Now it's a constant throb."
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Layer 2: The Urological / STI Screen:
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If asked about passing urine (Dysuria): "Yeah, it actually stung quite a bit when I peed this morning."
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If asked about discharge from the penis: You sound highly embarrassed. "Um... yeah. I noticed a little yellowish drop in my boxers yesterday. I didn't know what it was."
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Layer 3: The Sexual History:
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If the doctor asks for a sexual history (Partners, Protection): "I broke up with my girlfriend a few months ago. I slept with someone new about two months ago. We didn't use a condom. Do you think this is an infection?"
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Layer 4: Exploring the Core Fear (ICE):
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If asked what you were worried it might be: "I was up all night Googling it. With the lump and the swelling... I thought it was testicular cancer. My uncle had it when he was my age."

ICE — Ideas, Concerns, Expectations

The patient does not raise any of the following unprompted. These responses surface only when the candidate directly explores the patient's perspective.

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Ideas: Liam believes the swelling is likely testicular cancer. He has been Googling his symptoms obsessively and the combination of a swollen, painful testicle plus his uncle's history has convinced him it is malignant. The possibility that this could be an infection has not occurred to him — he does not connect the sexual encounter two months ago with his current symptoms.
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Concerns: His deepest fear is that he has cancer and that he has left it too long by waiting three days. He is also privately terrified about the social embarrassment of having an STI — if the doctor raises this possibility, he becomes visibly uncomfortable and worries about whether his new partner needs to be told. He is anxious about needing an intimate examination but accepts it is necessary if the doctor explains why.
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Expectations: He wants to be seen face-to-face today so someone can physically check the testicle and tell him definitively whether it is cancer or not. He wants a clear plan — he does not want to be told to "wait and see." If reassured it is not cancer, he is willing to follow whatever pathway the doctor recommends, including attending a sexual health clinic.

If Asked — Medical History and Medications

Liam has no significant past medical history, takes no regular medications, and has no known drug allergies. If the candidate asks:

●If asked about past medical history: "No, nothing. I've never really been to the doctor for anything serious. I think the last time I came in was for a dodgy knee from five-a-side, and that was about three years ago."
●If asked about regular medications: "No, I don't take anything. Just ibuprofen for this pain, but it's barely touching it."
●If asked about allergies: "No, no allergies that I know of."
●If asked about previous STI testing or results: "No, I've never been tested. Never had any reason to before."
●If asked about childhood illnesses or operations (e.g. undescended testis, orchidopexy): "No, nothing like that. Everything was normal as far as I know."

Social History and Lifestyle Impact

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Occupation and daily life: Liam works as a freelance graphic designer from home. He spends most of his day sitting at a desk. He lives in a shared house with two housemates.
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Lifestyle impact of the condition: "I can barely sit at my desk to work — the pressure makes the throbbing so much worse. I've had to turn down two client jobs this week because I just can't concentrate through the pain. I'm freelance, so if I don't work, I don't get paid. I've basically been lying on the sofa with a cushion between my legs for three days. I can't even go for a run — I usually play five-a-side on Thursdays but there's no chance of that right now."
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Alcohol / smoking / recreational drugs: If asked: "I drink socially — maybe a few pints at the weekend. I don't smoke. No drugs."

If Asked — Associated Symptoms

The patient does not volunteer any of the following. These responses are given only if the candidate asks directly.

●If asked about fever or feeling hot/cold: "Actually yeah, I did feel a bit hot and shivery last night, but I thought I was just run-down."
●If asked about nausea or vomiting: "No, I haven't felt sick or anything like that."
●If asked about abdominal or loin pain: "No, no tummy pain. It's all down below — the testicle and up into the groin."
●If asked whether the pain woke him from sleep or came on suddenly during the night: "No, it didn't wake me up suddenly. It's been building up gradually over the three days."
●If asked about scrotal redness or skin changes: "Yeah, it does look a bit red and shiny on that side, now you mention it."
●If asked about trauma or injury to the area: "No, I didn't bang it or anything. It just started hurting out of nowhere."
●If asked about heavy lifting or straining: "No, nothing like that. I sit at a desk all day."
●If asked about a lump separate from the swelling (discrete testicular mass): "I can't really tell — the whole thing is so swollen I can't feel where one bit ends and another starts."
●If asked about urinary frequency or urgency: "Maybe a bit more than usual, yeah, now I think about it."
●If asked about haematuria (blood in urine): "No, no blood."
●If asked about pain or swelling in joints: "No, nothing like that."
●If asked about any rash, skin lesions or mouth ulcers: "No, nothing."
●If asked about eye symptoms (pain, redness, visual changes): "No, my eyes are fine."
●If asked about rectal pain or symptoms: "No, nothing like that."
●If asked about weight loss or night sweats: "No, nothing like that."
●If asked about pain in the right testicle: "No, the right one is completely fine. It's just the left."

Negotiation & Collaborative Management Plan:

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If the Doctor attempts to diagnose and prescribe over the phone:
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Reaction: "So I don't even need to come in? You can just send antibiotics to the pharmacy for a swollen testicle?" (Candidate critically fails for diagnosing an acute scrotum without palpation and mismanaging the BASHH pathway).
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If the Doctor just tells you to go straight to a Sexual Health (GUM) clinic without a GP check:
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Reaction: "Go to the clinic? But what if it's cancer or something twisted? Don't you need to check it first to make sure it's actually an STI?" (Candidate fails for poor triage logic—GUM clinics do not manage surgical emergencies).
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If the Doctor mandates an urgent GP Face-to-Face to rule out surgical causes, then explains the GUM pathway:
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Reaction: "Okay, that makes complete sense. So you physically examine it today to make sure it's nothing twisted or dangerous, and if it is an infection, you send me to the sexual health clinic for the specific swabs and injections? I'll come to the surgery right now."

Additional Scripted Responses (Data Gathering):

●If asked about fever or feeling systemically unwell: "I've felt a bit off and hot the last day or so, but I haven't taken my temperature."
●If asked whether the recent partner has had any symptoms: "I haven't spoken to her since. I don't know. Should I contact her?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

1. Diagnostic Distinction: Epididymo-Orchitis vs Testicular Torsion

The clinical priority in any acute scrotum is to distinguish an STI-associated epididymo-orchitis from testicular torsion — a surgical emergency requiring orchidopexy within hours to preserve testicular viability.

●Torsion: Typically sudden, severe onset — often waking the patient from sleep. Peak incidence in adolescence (12–18) but can occur at any age. Associated with nausea and vomiting. The cremasteric reflex is typically absent. The Prehn sign (pain relief on testicular elevation) is absent.
●Epididymo-orchitis: Gradual onset over days. Associated with dysuria, urethral discharge, and urinary frequency. Fever and systemic upset may be present. Cremasteric reflex is usually intact.
●In a 25-year-old with a 3-day history of gradual-onset pain, dysuria, and urethral discharge, epididymo-orchitis is the strongly favoured diagnosis — but definitive exclusion of torsion requires physical examination and cannot be accomplished remotely.

2. The Acute Scrotum Triage Pathway

The correct triage disposition is the central clinical skill tested in this station.

●Do not send directly to GUM: Sexual health clinics are not resourced to manage surgical emergencies. If the presentation is torsion, attending GUM wastes critical ischaemic time.
●Do not manage remotely and prescribe by phone: An acute scrotum cannot be fully assessed without palpation. Remote prescribing without examination is a patient safety failure.
●Do not reflexively send to A&E: Where the history is strongly consistent with gradual-onset infection, same-day GP face-to-face examination is the appropriate first step — A&E referral should be reserved for cases with high torsion suspicion or systemic deterioration.
●Correct pathway: Urgent same-day GP face-to-face → clinical examination to exclude torsion → if infection confirmed, refer to GUM for NAAT swabs and BASHH-guided treatment.

3. Red Flags Requiring Emergency Escalation

Certain features should prompt immediate ED referral rather than same-day GP review.

●Sudden severe onset of testicular pain — particularly if waking from sleep
●Absent cremasteric reflex on examination
●Pain not improving or worsening rapidly despite initial assessment
●High fever, rigors, or signs of systemic sepsis
●Clinical examination findings suspicious for abscess formation or vascular compromise

Safety-net all patients with an acute scrotum that the pain character and clinical picture can change, and that they should go to A&E if pain becomes sudden and severe before their appointment.

4. BASHH Antibiotic Pathway for Epididymo-Orchitis in Men Under 35

In men under 35, epididymo-orchitis is considered sexually transmitted until proven otherwise, with Chlamydia trachomatis and Neisseria gonorrhoeae as the principal causative organisms.

●First-line BASHH regimen (2020): IM ceftriaxone 500mg stat (covers gonorrhoea) plus oral doxycycline 100mg twice daily for 10–14 days (covers chlamydia)
●Why GUM, not GP: Most GP surgeries do not routinely stock IM ceftriaxone. GUM clinics can also perform first-catch urine and urethral NAAT swabs (nucleic acid amplification testing) for gonorrhoea and chlamydia — essential for microbiological confirmation and medicolegal contact tracing
●Allergy check is mandatory before committing to this pathway: a significant penicillin or cephalosporin allergy (anaphylaxis, angioedema, urticaria) requires an alternative regimen. In confirmed or suspected cephalosporin allergy, discuss with GUM — options include ofloxacin 200mg twice daily for 14 days where gonorrhoea has been excluded
●In men over 35, enteric organisms (E. coli, Pseudomonas) become more prevalent. Consider ofloxacin 200mg twice daily for 14 days or levofloxacin 500mg once daily for 14 days as an alternative

5. Supportive Management

Do not overlook supportive measures — they have a direct impact on patient function and comfort while awaiting definitive treatment.

●Analgesia: Optimise beyond a subtherapeutic ibuprofen-alone regimen. Advise regular ibuprofen 400mg three times daily with food plus regular paracetamol 1g four times daily — combination analgesia is substantially more effective than a single agent taken irregularly
●Scrotal support: Supportive underwear or elevation of the scrotum reduces dependent oedema and relieves the sensation of heaviness
●Rest: Advise avoidance of strenuous activity until the acute episode resolves

6. Partner Notification

Partner notification is a clinical and public health obligation in all confirmed or probable STI cases — not an optional add-on.

●The recent sexual partner is at risk of gonorrhoea and chlamydia and may be entirely asymptomatic
●Raise this sensitively as an act of care for someone else, not as a punitive measure
●The GUM clinic will provide dedicated partner notification support — including the option of patient-initiated or clinic-initiated notification — which removes the burden from the GP to manage this directly
●Document that partner notification has been discussed

7. Test of Cure and Long-Term Follow-Up

Incomplete or inadequate treatment of epididymo-orchitis carries a significant risk of long-term complications.

●Test of cure for gonorrhoea: BASHH recommends a test of cure at two weeks post-treatment for all gonorrhoea cases, given increasing antimicrobial resistance
●Complete the full course: Emphasise to the patient that the full antibiotic course must be completed even if symptoms resolve early — undertreated epididymo-orchitis risks chronic epididymitis, epididymal obstruction, and subfertility
●GUM follow-up will coordinate test of cure, review of swab results, and assessment of treatment response

8. Distinguishing Infection from Testicular Cancer

Testicular cancer is the most common cancer in men aged 15–35, and unaddressed cancer fear will undermine the patient's engagement with the management plan.

●Features suggesting infection rather than malignancy: Diffuse, hot, tender swelling throughout the testicle; associated urethral symptoms; systemic features (fever); gradual onset correlated with a sexual exposure
●Features suggesting malignancy: Typically a painless, discrete, firm, irregular mass within the body of the testis — often noticed incidentally. Malignant masses are not usually acutely hot or tender, and are not associated with dysuria or urethral discharge
●A family history of testicular cancer (e.g. first-degree or second-degree male relative) is a recognised risk factor and increases the importance of physical examination and, if any diagnostic doubt persists after treatment, ultrasound
●Clinical explanation: Offer the patient a clear and accessible explanation of why the clinical picture points to infection — this is essential for informed consent to the management pathway and to avoid the patient remaining in a state of unresolved cancer terror

9. GMC Guidance: Remote Intimate Examinations

The GMC is explicit that remote intimate examinations should not be conducted routinely.

●Visual inspection of the genitals via video call is both a GMC policy breach and clinically useless for an acute scrotum: it cannot replace palpation, does not allow assessment of cremasteric reflex, and cannot detect a discrete intratesticular mass
●The correct response is always to arrange face-to-face examination — not to attempt a remote workaround
●Asking a patient to expose themselves in their home environment without a proper chaperone and remote examination protocol in place is an unjustifiable breach of dignity and professional standards

Free MRCGP SCA practice case for GP registrars covering Remote Triage of the Acute Scrotum — Sexual Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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