A Pain in the… Side?

Presentation

A 52 year old male with a past medical history of frequent nephrolithiasis presented to the emergency department with complaint of “left-sided flank pain.” He described pain for the past day which was constant, radiated to the left lower quadrant, and was 9/10 in severity. He endorsed associated nausea, hematuria, dysuria, loose stools, chills, and hot and cold flashes. He denied recent fever, vomiting, diarrhea, rectal bleeding, or any other associated symptoms or complaints.

On initial presentation, the patient was afebrile and hemodynamically stable. On exam, the patient had left CVA tenderness but the rest of his exam was normal; GU exam was not performed.

Workup/ED Course

CT Abdomen/Pelvis: “At least 10 calcifications left kidney largest 10 mm inferior pole. There is some rim calcification and a kidney cyst. At least 10 calcifications right kidney largest lower pole 10 mm... no hydronephrosis is seen.” No calcification noted in the ureters.

Urinalysis showed large leukocyte esterase, >50 WBC with bacteria, and moderate blood with RBCs.

The patient was discharged home with diagnoses of “nephrolithiasis and urinary tract infection” and was prescribed Percocet, Zofran, ibuprofen, Keflex, and Flomax.

Bounceback

Two days later, the patient returned to the ED with a chief complaint of “testicular pain.” He reported a gradual onset of pain in the left testicle that had begun since his discharge from the ED. He described the pain as sharp in nature and nonradiating, with associated testicular swelling, subjective fever and chills.

Testicular ultrasound: “Asymmetric enlargement and hypoechoic left testicular parenchyma with no flow on color spectral doppler images... findings are highly concerning for torsion. Asymmetric enlargement and hypervascularity of the left epididymis, which can be seen in the setting of epididymitis.”

Outcome

Urology was consulted and the patient was taken emergently to the OR. He was found to have an “infarcted, black left testis with erythematous inflamed left epididymis, significant periadnexal edematous reaction.” No testicular torsion was present.

A left orchiectomy was performed, and the patient was discharged home the next day.

Takeaway Points

• Consider epididymitis in male patients presenting with dysuria

• Severe epididymitis can present similarly to testicular torsion and cause infarction of the testes due to severe edema

• Consider alternative diagnoses when patients with active flank pain do not have ureterolithiasis or hydronephrosis on imaging

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