Correspondence

Aortic Dissection Presenting as Bilateral Testicular Pain

N Engl J Med 2000; 343:1199October 19, 2000

Article

To the Editor:

A 77-year-old man came to the emergency room with a two-day history of sharp bilateral testicular pain. He had no history of trauma, fevers, chills, abdominal or back pain, dysuria, hematuria, penile discharge, frequency, or urgency. The pain had begun while he was resting in bed and had progressively worsened. His medical history included hypertension, chronic obstructive pulmonary disease, chronic renal insufficiency, and anemia. He had no history of renal calculi. His outpatient medications consisted of fosinopril and inhaled albuterol and ipratropium. The patient's temperature was 36.8°C, his blood pressure was 198/110 mm Hg, and he had a pulse of 85 per minute, a respiratory rate of 22 per minute, and an oxygen saturation of 93 percent (while receiving 2 liters of oxygen by nasal cannula). The physical examination was notable only for exquisitely tender testicles; there was no swelling, erythema, or masses. The pain remained constant despite manipulation and changes in position.

An electrocardiogram showed sinus rhythm and no abnormal changes. A chest radiograph showed hyperinflated lungs and flattened diaphragms. The white-cell count was 11,200 per cubic millimeter (80 percent neutrophils), the hemoglobin level was 10 g per deciliter, the platelet count was 240,000 per cubic millimeter, the blood urea nitrogen level was 36 mg per deciliter, and the creatinine level was 1.7 mg per deciliter.

The patient was admitted for observation and pain control. Three hours later, he became acutely hypotensive and pulseless. Electrical activity on the cardiac monitor was consistent with the presence of pulseless electrical activity. The patient died despite vigorous resuscitative efforts; the hemoglobin level during these efforts was 6.8 g per deciliter. Autopsy showed extensive Stanford type A aortic dissection, pericardial effusion, left hemothorax, and massive hemoperitoneum.

The aortic dissection was manifested only by bilateral testicular pain. The pain was most likely secondary to compression of the surrounding nerves by the expanding aneurysm. The differential diagnosis of testicular pain as the sole symptom includes epididymitis, orchitis, testicular torsion, renal calculi (referred pain), incarcerated hernia, torsion of testicular appendages, hydrocele, prostatitis, appendicitis, trauma, testicular tumor, varicocele, spermatocele, and vasculitis (such as polyarteritis nodosa or Schönlein–Henoch purpura).1 However, these conditions rarely, if ever, present bilaterally. The most important risk factors for acute aortic dissection are hypertension, advanced age, and aortic-wall disease — two of which this patient had.2 Despite advances in the diagnosis and management of acute aortic dissection, the rates of morbidity and mortality remain high, with in-hospital mortality rates of 27 to 30 percent. Clinical vigilance is essential, since classic physical and radiographic findings are often absent in patients with aortic dissection.2-4

Kirk M. Chan-Tack, M.D.
University of Missouri–Columbia, Columbia, MO 65212

4 References

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   Artman MR, Burkle FM Jr. Acute abdominal aortic aneurysm presenting as isolated testicular pain. Am J Emerg Med 1987;5:45-47
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   Pretre R, Von Segesser LK. Aortic dissection. Lancet 1997;349:1461-1464
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   Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897-903
   CrossRef | Web of Science | Medline

4. 4

   Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642-651
   Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Luca Cacciotti, Giovanni S. Camastra, Salvatore Musarò, Ilaria Passaseo, Gerardo Ansalone. (2011) Abdominal aortic dissection with atypical presentation. Internal and Emergency Medicine 6:2, 193-194
   CrossRef

2. 2

   Richard A. Harrigan, Michael A. DeAngelis. 2007. Evaluation and Management of Patients with Chest Syndromes. , 1-16.
   CrossRef