A rare case of leaking abdominal aneurysm presenting as isolated right testicular pain

Case Reports

CJEM 2007;9(2):124-126

Abstract

Résumé

Introduction

An abdominal aortic aneurysm (AAA) is a potentially serious disease that typically develops in patients over 50 years of age and is more frequently seen in association with hypertension or a familial history of aneurysm. In asymptomatic patients, it may be detected during a routine screening abdominal ultrasound. Ruptured or leaking aneurysms can be fatal unless treated swiftly. Common presenting features are abdominal or back pain and a pulsatile abdominal mass in association with hemodynamic instability or shock.

On rare occasions, left testicular pain may accompany other more classic symptoms of a leaking AAA.1-4 Because the aorta lies to the left of the midline, atypical symptoms are usually localized in the left side. The diagnosis is commonly confused with mechanical lumbar back pain, renal colic, diverticulitis and incarcerated hernia.5 Left-sided and bilateral testicular pain due to AAA has also been described in the literature.6 A review of the literature could not identify any report of patients with leaking aneurysms presenting with isolated acute right testicular pain. This case report is about such a presentation.

Case Report

A 62-year-old delivery male presented to the accident and emergency department of Yeovil District General Hospital, UK, with a 6-hour history of progressively severe right testicular pain that did not respond to acetaminophen and ibuprofen.

The patient denied having any history of trauma, casual sex, dysuria, frequency or haematuria. He had a past medical history of hypertension, right total knee replacement for osteoarthritis and juvenile osteoporosis. His regular list of medications included ramipril and diclofenac. He also used Co-dydramol (dihydrocodeine tartrate 10 mg, Paracetamol 500 mg) on occasion for his osteoarthritis. He was a non-smoker and drank alcohol socially.

On physical examination, the patient was overweight (130 kg), and his vital signs were normal (pulse 87 beats / min, blood pressure [BP] 147/68 mm Hg, temperature 36.8°C, respiration 24 breaths/min and SaO₂ 98% on room air). The patient appeared generally well; examination of his abdomen, urogenital tract and lumbo-sacral spine were unremarkable. Initially, the cardiovascular system was not formally examined. Scrotal examination showed no evidence of trauma, inflammation or enlargement of the testis. A bedside urinalysis revealed only minor proteinuria.

The patient was initially diagnosed with right epididymo-orchitis. Before deciding to discharge the patient with antibiotics, we sought a urology-surgical consultation to exclude the possibility of testicular torsion or torsion of a testicular appendage.

When the patient was evaluated by the urologist-surgeon 2 hours later, he complained of a new right flank pain in addition to his existing right testicular pain. His vital signs had also changed slightly (pulse 98/min and a slightly narrowed BP 130/85 mm Hg). A repeat examination of the abdomen and scrotum again revealed no abnormality. There was no pulsating abdominal mass or evidence of peripheral emboli. All peripheral pulses were present and symmetric. Blood tests included hemoglobin 12.6gm/dl, white blood cell 14.3 × 10⁹/l, platelet 1.8 × 10¹²/l, urea 12mg/dl, creatinine 94mmol/l and international normalized ratio 1.3. The surgeon suspected the patient had a right ureteric stone and ordered an intravenous urogram. The initial plain film revealed calcification consistent with an AAA (Fig. 1). A contrast CT scan of the abdomen was immediately requested and revealed an 8.9 cm leaking AAA associated with a large hematoma in the right retroperitoneum (Fig. 2).

The patient remained hemodynamically stable and was transported to the regional vascular unit, where he underwent an emergency laparotomy 12 hours after the onset of his symptoms and 6 hours after initial hospital presentation. A leaking AAA with a large right sided hematoma was confirmed during surgery. The aneurism was successfully repaired, and the patient recovered uneventfully.

Discussion

Acute scrotal pain is a potential surgical emergency. Common causes include trauma, testicular torsion, torsion of testicular appendage and epididymo-orchitis.7 Uncommon causes include leaking AAA and testicular microlithiasis.8 A ruptured or leaking AAA is an uncommon surgical emergency with a high mortality rate, and survival for those reaching the hospital alive is approximately 50%.9 Most patients are older than 50 years of age and present with abdominal pain radiating to the back in association with a pulsatile abdominal mass and hypovolaemic shock.9 Rarely, presenting symptoms can mimic renal colic, testicular torsion, diverticulitis, gastrointestinal hemorrhage or spinal arthritis.9,10 Diagnostic delay can adversely affect survival.11

The aorta usually lies to the left side of the midline in the retroperitoneum. Consequently, retroperitoneal hematoma irritating the lumbar plexus and the genito-femoral nerves have generally been reported on the left side.12 A leaking AAA is often suspected in the presence of left flank and groin pain, right buttock and hip pain in association with shock, or lower abdominal pain radiating to the right testicle1,13; however, isolated, acute, right testicular pain in the absence of other symptoms or signs has not been previously reported. It is important to consider this diagnosis in the appropriate patient group.

Conclusion

This case demonstrates that leaking AAA should also be considered in the differential diagnosis of isolated, right-sided testicular pain in patients aged 50 years and older who have normal genitalia on examination. An emergency bedside ultrasound or an unenhanced CT scan may be indicated in these patients. Early suspicion may help avoid unnecessary delays in instituting the appropriate investigations and treatment in future patients with similar symptoms.