A 65‐year‐old Caucasian male smoker with a past medical history of coronary artery disease, diabetes mellitus, hypertension and dyslipidemia, presented to the emergency department with the complaint of sudden onset right testicular pain of one hour’s duration. It was intermittent, sharp, non‐ radiating, associated with painful, spasmodic micturition. He denied any history of trauma, abdominal pain, hematuria, fever, nausea and vomiting. On arrival, he appeared to be in mild distress and had a significantly elevated blood pressure of 225/108 mmHg. Physical examination was remarkable only for mild right testicular tenderness. There was no scrotal edema, erythema, or testicular enlargement. Routine labs and urinalysis were within normal limits. A non‐contrast computerized tomography scan of the abdomen was obtained on the suspicion of a ureteric colic, which revealed a large infra renal saccular aortic aneurysm, measuring 7cm (transverse) by 6.2cm (anteroposterior) extending up to the iliac bifurcation. Additionally, there was subtle stranding of the peri‐aortic tissues suggestive of a leak. No ureteric or renal calculi were found. A Nitroprusside drip was immediately started for control of hypertension and vascular surgery was emergently consulted for repair of the aneurysm. However, while arrangements for aneurysm repair were under way, our patient suddenly became hypotensive and unresponsive. His abdomen was distended with bluish discoloration. Despite aggressive resuscitation, the patient expired.
Early detection of a leaking abdominal aortic aneurysm could be life saving; a delay would inevitably be catastrophic. Only around 50% of patients present with the typical triad of abdominal pain or back pain along with a pulsatile abdominal mass and hemodynamic compromise, delaying this fatal diagnosis. Hence, it is imperative for clinicians to be aware that the presentation may mimic more common conditions such as urolithiasis, testicular torsion or epididymo‐orchitis. Testicular pain that occurs in the presence of a leaking aneurysm is referred pain. It is postulated to be due to compression of the genito‐femoral and/or ilio‐inguinal nerves by the expanding aneurysm or developing hematoma, as they course through the psoas muscle. Typically there would be no local signs of inflammation. Since the retroperitoneal aorta lies to the left of the midline, left sided symptoms occur more commonly. A leaking aneurysm presenting solely as acute right sided testicular pain is rare.
Our case highlights the importance of entertaining a ruptured or leaking abdominal aortic aneurysm in the differential of acute right testicular pain in elderly males, especially those with hypertension and ongoing smoking which are both risk factors for aneurysm development as well as for aneurysm leak and rupture.
To cite this abstract:Fernando P, Chandra K, Kumar J. An Acute Scrotum: Could It Be Fatal?. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 414. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/an-acute-scrotum-could-it-be-fatal/. Accessed April 1, 2020.