Making the Diagnosis
To accurately assess and diagnose this patient’s condition, the clinician needs to consider conditions that would cause testicle pain, vomiting, kidney disease, and dysuria yet have a normal testicular examination, normal urine assay, and normal scrotal ultrasonography imaging. It is important to always consider the worst-case scenario. In this case, referred pain from the retroperitoneum should be considered. This patient is likely too young for an abdominal aortic aneurysm but an aortic dissection is not out of the question. Given the patient’s history of untreated HIV, a retroperitoneal tumor or indolent infectious process should also be a consideration.
The CT scan of the abdomen shows severe right-sided hydronephrosis (Figure 1) caused by a large right renal mass (Figure 2). This could represent either a tumor or an indolent infectious process; however, given the patient’s lack of fever, a tumor would be more likely the cause
Discussion
Referred pain typically co-occurs with pain in the primary site but occasionally occurs alone as in this case. Other examples of referred pain are shown in the table.
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Table. Site of Referral Pain and Possible Causes
| Site of Pain | Cause |
| Ear/Dental | Cardiac condition, tonsillitis |
| Neck/trapezius | ACS, pericarditis, aortic dissection (extension of the aortic dissection up into one of the carotid arteries) |
| Arm | ACS (left arm is more sensitive, but right or bilateral arm is more specific) |
| Shoulder | Peri-diaphragmatic condition (pneumonia, pulmonary embolism, splenic rupture, hemoperitoneum) |
| Testicle | Retroperitoneal condition (abdominal aortic aneurysm, aortic dissection, kidney stone, renal mass) |
| Thigh | Ovarian condition |
Case Conclusion
The patient in this case was referred to a tertiary care center and eventually diagnosed with lymphoma.
Brady Pregerson, MD, is an emergency physician at Tri-City Medical Center, Palomar Health System, and Scripps Coastal Urgent Care, all in San Diego, California.
References
Pregerson DB. Urology. Emergency Medicine 1-Minute Consult. 5th ed. 2017;5. http://www.erpocketbooks.com/emergency_medicine_reference_books/quick-essentials-emergency-medicine/
This article originally appeared on Clinical Advisor
