Acute testicular pain secondary to a leaking abdominal aortic aneurysm (AAA)

Abstract

We present the case of a 56-year-old male smoker with a background of hypertension who presented with acute onset right testicular pain secondary to a leaking abdominal aortic aneurysm. Following urgent surgical repair and a complicated intensive care recovery, the patient was discharged with no residual disability. This case highlights an atypical presentation of what is a devastating illness.

Background

A ruptured abdominal aortic aneurysm (AAA) carries high mortality, and outcome is heavily dependent on prompt recognition and timely surgical intervention. Diagnosis can particularly be delayed if a patient presents in an atypical fashion, and this can result in a poorer prognosis. As such, it is important to recognise the different ways in which a leaking or ruptured AAA can present.

Case presentation

A 56-year-old man with a history of hypertension and a smoking history of 60 cigarettes per day for 40 years presented to the accident and emergency department with acute onset right testicular pain and vomiting. The pain had been confined to the right testicle only and had been increasing in severity throughout the course of the day. On presentation, the patient was haemodynamically stable and without fever. He denied any lower urinary tract symptoms, urethral discharge, abdominal pain, change in bowel habit, loss of appetite or weight loss. Examination of the testes was unremarkable, and the abdomen was soft and non-tender throughout. A reducible inguinal hernia was palpated on the right side which was mildly tender to palpation. The white cell count was raised (27.1 x 10^9/l) but C-reactive protein, haemoglobin, urea and electrolytes and liver function tests were all within normal limits.

While awaiting surgical review, the patient became cold, clammy and confused. Repeat observations revealed hypotension and tachycardia while a repeat haemoglobin reading was 83 (compared with the previous level of 131). A bedside ultrasound scan of the abdomen was performed which showed an approximately 6 cm AAA. CT imaging of the abdomen confirmed a 6.7 cm ruptured subrenal AAA, with a significant amount of free haemorrhagic fluid within the abdominal cavity (figure 1). An emergency midline laparotomy by the vascular team confirmed a large retroperitoneal rupture of the aorta. The inferior mesenteric vein was ligated, and the infrarenal and common iliac arteries were clamped bilaterally. A proximal anastomosis to the infrarenal aorta and distal anastomosis to the origin of the common iliac arteries were performed. A left femoral thrombectomy was also performed as the patient’s left foot was found to be ischaemic. Following the successful repair, the patient was admitted to the intensive care unit (ICU) for further optimisation and continued invasive respiratory support and close monitoring.

Figure 1.

CT scan showing the 6.7  cm ruptured abdominal aortic aneurysm.

His intensive care admission was complicated with acute kidney injury secondary to prolonged hypovolaemia and hypotension, and potentially due to raised intra-abdominal pressure. On day 2 of ICU admission, the patient developed thick endotracheal secretions with culture results revealing Escherichia coli infection for which he was started on piperacillin–tazobactam and later ertapenem following sensitivity results. On day 4 of ICU admission, a sedation hold was attempted whereby the patient was found to have left arm weakness and a mild expressive aphasia. A CT scan of the head revealed an established infarct within the right centrum semiovale extending inferiorly into the right corona radiata. On recommendation of the stroke team, 300 mg of aspirin was started. The patient was successfully extubated on day 10 of ICU admission. By now, his left arm weakness had improved slightly but he failed repeated swallowing tests. MRI of the head was requested in order to gauge the significance of cerebral injury which highlighted multiple, bilateral, hyperintense foci within the periventricular white matter, central semiovale and brain stem, all of which were probably the result of prolonged hypotension and hypovolaemia. Ultrasound of the carotid arteries did not reveal any significant stenosis. ICU admission was further complicated by prolonged ileus, refractory hypertension and delirium, all of which resolved by day 15 of ICU admission, enabling transfer to the stroke ward for ongoing rehabilitation. The patient spent 8 days on the stroke ward before being discharged home.

Outcome and follow-up

On follow-up, this patient was doing well with no persisting neurological deficit but had not been able to return to work as an heavy goods vehicle (HGV) driver.

Discussion

An AAA is an abnormal, focal dilatation of the abdominal aorta 50% greater than its normal diameter.¹ The majority of AAAs occurs in the infrarenal region.² Risk factors for the development of an AAA include: smoking, hypertension, male gender, age, atherosclerosis and connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome.³

Most individuals with an AAA are asymptomatic with their aneurysm being discovered as a result of routine screening, a perchance finding of a pulsatile mass on routine abdominal examination or as a result of imaging carried out for some other indication.^{4 5} A ruptured AAA typically presents with haemodynamic instability and abdominal pain which has been reported to radiate to the back, flank, pelvis and groin. There may be features of limb ischaemia due to embolism of thrombus or atherosclerotic debris or systemic features related to an infected or inflammatory aneurysm.⁶ Features such as nausea, dizziness or syncope may also be present.

Ruptured AAA presenting as acute testicular pain is highly unusual with only 10 cases being reported in the literature.^7–15 These patients all presented with an acute history of testicular pain with entirely benign testicular and abdominal examination, as well as being haemodynamically stable on admission. All patients had a history of hypertension, were male and with the exception of one patient were all smokers. The mechanism behind such a presentation could be due to posterolateral expansion of the aneurysm causing compression of the afferent pain fibres from the testes.¹⁰ These pain fibres pass from the pelvic splanchnic nerves via the hypogastric plexus and inferior splanchnic nerves to end up at the dorsal roots of T9–L1. The inferior splanchnic nerves traverse through the psoas muscle where a lateral expansion of an aneurysm can produce a referred pain phenomenon to the testes.

Patient’s perspective.

‘I am grateful for the care I received. I have not returned to work yet but hope to be able to in the near future.’

Learning points.

• A ruptured abdominal aortic aneurysm is associated with a high mortality rate.

• Prompt diagnosis and thus management is crucial.

• Testicular pain is an unusual presenting feature of a leaking or ruptured abdominal aortic aneurysm but in a patient with known risk factors for atherosclerotic disease should be considered in the differential diagnosis, particularly when the diagnosis is not initially obvious.