Brian Nguyen: A 23 Year-Old With Severe Testicular Pain and Hematuria

Learning Objectives

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Learn the common causes of testicular pain.
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Develop an understanding of the unique anatomy of the urinary tract.
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Develop an understanding of the sensory innervation of the urinary tract.
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Develop an understanding of the causes of pain associated with nephrolithiasis.
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Learn the clinical presentation of nephrolithiasis.
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Learn testing options to diagnosis nephrolithiasis.
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Learn how to use physical examination to diagnose nephrolithiasis.
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Develop an understanding of the treatment options for the various types of pain associated with nephrolithiasis.

Brian Nguyen

Brian Nguyen is a 23-year-old student with the chief complaint of, “Something is stabbing my left nut and I’m peeing blood.” Brian stated that he was awakened from a sound sleep with the worst pain he had ever experienced. He stated that it was worse than the time he broke his leg when he tripped over a curb. “Doctor, please help me! Give me something for the pain. I can’t take much more!” begged Brian. With every paroxysm of pain, Brian closed his eyes, whimpered, and paced the exam room. It was obvious he was in a lot of pain. Brian said that the pain would come out of nowhere, like someone kicked him in the nuts, and then it went away as quickly as it came. “Doctor, the pain hits and it doubles me over.” Brian went on to say that he felt like he had to pee every 4 or 5 minutes, but when he tried to pee, he had to really strain to get any pee out. And when it came out, it was bloody. “Doctor, please help me. I’m afraid that I will bleed to death. Do you think I have cancer?” Brian said he felt like he needed to throw up but was afraid to because he thought it would make the pain worse. I asked, “Brian, is the pain on both sides or just on one side?” He responded, “It’s always in my left nut and up by my kidney. It’s never on the right.” Brian went on to say that he had tried extra-strength Tylenol, but the pain just continued to get worse. I asked Brian if he ever had anything like this happen before, and he shook his head no. I asked what made it better, and he said nothing. He thought that moving around helped a little, but that nothing he has tried has really worked. Brian denied any fever or chills, but volunteered that he felt horrible.

On physical examination, Brian was afebrile. His respirations were 18, and his pulse was 88 and regular. His blood pressure was 158/88. I checked for costovertebral angle (CVA) tenderness, and when I percussed his left CVA area, Brian immediately cried out in pain and came off the exam table. He whimpered in pain and said, “Doctor, I’m begging you, warn me when you are going to do that again. It’s really bad, and I need to have something to hold on to.”

When I told Brian I wanted to examine his testicles, he got really upset. “Doctor, I’m begging you, please put me out before you do! I just don’t know how much more of this pain I can take. It’s horrible, worse than anything you can imagine. I did not know that anything could hurt this bad!” I said, “Let’s start with the right testicle, Brian, and go from there. How about that?” Brian was reluctant, but said, “Do what you have to do, Doc. I have to get rid of this pain or I am done for. I am afraid of what I might do if this pain continues. I don’t think I can take much more. Doctor, let me ask you something. What did I do to deserve this? I try to do good!” His right testicle exam was normal, and with great convincing, I got a quick look and feel of his left testicle, which appeared and felt completely normal. There was minimal pain with palpation. Brian was a little tender over his bladder, but I felt no abnormal mass. His fundoscopic examination was normal, as was the rest of his head, eyes, ears, nose, throat (HEENT) exam. His cardiopulmonary examination and thyroid were normal. His abdominal examination revealed no abnormal mass or organomegaly. There was no peripheral edema.

I asked Brian to point with one finger to show me where it hurt the most, and with great care to avoid touching his groin, he pointed to his left testicle. “Doctor, the pain starts way down deep in my left nut, way down deep and it shoots up into the tip of my penis.” I told Brian that I was pretty sure that I knew what was going on and that we had a lot of treatment options to get on top of this pain. Brian replied, “I hope to hell you know what you are talking about, but first I really, really, really have to pee.” I handed him a specimen cup. Brian limped off to the bathroom, and a few minutes later he returned and handed me his cup, which was full of blood.

Key Clinical Points—What’s Important and What’s Not

The History

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No history of previous testicular pain or hematuria
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No fever or chills
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Recent onset of severe unilateral testicular pain with associated hematuria
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Urinary frequency, urgency, and stranguria
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Onset to peak of the pain is immediate
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Pain is episodic, with pain-free periods
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High degree of anxiety regarding pain and associated hematuria

The Physical Examination

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Patient is afebrile
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Severe left CVA tenderness
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Testicular examination is normal
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Tenderness over bladder
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Urine with gross hematuria

Other Findings of Note

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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal neurologic examination, motor and sensory examination
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No pathologic reflexes

What Tests Would You Like to Order?

The following tests were ordered:

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Dual-energy noncontrast abdominopelvic computed tomography (CT) to identify the location of the suspected kidney stone and to try and characterize its composition
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Urinalysis to identify the presence of blood, crystals, and bacteria and urinary pH (as a pH >7 suggests the presence of urea-splitting organisms such as Proteus, Pseudomonas, or Klebsiella bacteria, and/or the presence of struvite stones). A urine pH of less than 5 points the clinician toward the consideration of uric acid stones.
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Comprehensive metabolic panel, including serum creatinine and uric acid determinations, to clarify renal function and to identify the presence of hyperuricemia.
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Complete blood count (CBC) to rule out anemia of chronic disease and to identify leukocytosis associated with urosepsis.

Test Results

Dual-energy noncontrast abdominopelvic CT revealed a large stone in the left upper kidney, which was characterized as uric acid in composition ( Fig. 13.1 ).

Urinalysis revealed gross hematuria. Uric acid crystals were also identified. No nitrates were identified on the dipstick, and the pH was 5.2.

Comprehensive metabolic panel was normal other than a markedly elevated uric acid.

CBC revealed a hemoglobin of 15.4 and a white count of 10,200 with a slight left shift.

Clinical Correlation—Putting It All Together

What is the diagnosis?

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Nephrolithiasis (uric acid stone)

The Science Behind the Diagnosis

Anatomy of The Urinary tract

The upper urinary tract is comprised of the pelvicalyceal system of the kidney and the ureter ( Fig. 13.2 ). The lower urinary tract is comprised of the bladder and urethra. The kidneys lie in the retroperitoneal space at the level of the 12th thoracic vertebra. Due to the liver, the right kidney lies slightly lower than the position of the left kidney. The ureter emerges from the hilum of the kidney and runs in a straight trajectory vertically downward within the retroperitoneal space, lying on top of the psoas major muscle. Each ureter connects its respective kidney with the urinary bladder. There are significant differences in topographic relationships of the ureter in males versus females, specifically the presence of the uterine artery in females and the vas deferens in males ( Fig. 13.3 ).