Testicular Pain in a 57-Year-Old Man

Adam J. Singer, MD

Disclosures

November 30, 2001

Case Presentation

A 57-year-old man presented to the emergency department with acute onset of left testicular pain. He denied fever, chills, nausea, vomiting, voiding complaints, or recent genitourinary trauma. He had been kicked in the scrotum 45 years ago; the injury had resolved with observation and rest.

Three days earlier, the patient had presented to the emergency department with biliary colic. The ultrasound of the abdomen demonstrated several stones within the gallbladder without dilation of the cystic duct. The serum alanine aminotransferase, serum aspartate aminotransferase, lactic acid dehydrogenase, alkaline phosphatase, and total bilirubin were normal. His pain resolved after he received an oral preparation of Mylanta® (30 mL), Donnatal® (10 mL), and viscous xylocaine (5 mL), along with parenteral morphine and prochlorperazine (Compazine®). Once the pain resolved, he was referred to a general surgeon for a routine evaluation.

The patient's past medical history included a vasectomy in 1975 and a colonoscopic removal of a tubular adenoma of the sigmoid colon in 1993. He had no other medical problems and did not take any medication.

On physical examination his vital signs were: oral temperature, 98.9°F (37.2°C); respiration, 20 breaths per minute; heart rate, 85 beats per minute; and blood pressure, 117/81 mm Hg. The right intrascrotal contents were normal; however, the left testicle and epididymis were diffusely tender but not enlarged, and tethered high in the scrotum by an edematous spermatic cord. There were no palpable masses, but clear definition of landmarks in the left side of the scrotum were hampered by a new left hydrocele. The remainder of the physical examination was unremarkable. A CBC, serum electrolytes, blood urea nitrogen, creatinine, and prostate-specific antigen were normal. The urine was negative on dipstick analysis and demonstrated 0-2 WBCs per high-power field. A scrotal ultrasound showed a left hydrocele, normal testicles, and normal epididymides (Fig. 1). A nuclear orchiogram was also performed (Fig. 2).

Scrotal ultrasound showing normal left testicle and hydrocele.

Nuclear orchiogram demonstrating area of decreased density in region of left testicle.

What do you recommend as the next step?

  1. Observation

  2. Radical orchiectomy

  3. Scrotal exploration

  4. Antibiotics, anti-inflammatory agents, scrotal support, and rest

View the correct answer.

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