What imaging is warranted for a 64-year-old male veteran with worsening back pain radiating to his right testicle, accompanied by testicular and right groin pain?

Imaging for Back Pain with Testicular Radiation in a 64-Year-Old Male Veteran

Ultrasound of the scrotum/testicles should be the first imaging study, followed by CT abdomen/pelvis with contrast and lumbar spine X-rays to evaluate both potential urological and spinal causes of the patient's symptoms.

Initial Imaging Approach

1. Ultrasound of the Scrotum/Testicles

• Rationale: The American College of Radiology (ACR) rates ultrasound as the established first-line imaging modality for acute scrotal disease 1
• Provides prompt and highly accurate diagnosis of scrotal disorders
• Can evaluate for:
  • Testicular torsion
  • Epididymitis/orchitis
  • Testicular masses
  • Varicocele
  • Hydrocele
  • Abscess formation

2. CT Abdomen and Pelvis with IV Contrast

• Essential to evaluate for:
  • Retroperitoneal pathology
  • Ureteral stones
  • Abdominal aortic aneurysm
  • Malignancy
  • Referred pain from intra-abdominal processes
  • Fournier's gangrene (in severe cases)

3. Lumbar Spine X-rays

• Indicated for back pain with radiation to testicle
• Can identify:
  • Degenerative changes
  • Fractures
  • Alignment issues
  • Spondylolisthesis

Rationale for This Approach

The patient's presentation with back pain radiating to the testicle requires evaluation of both urological and spinal pathologies. This combination of symptoms suggests potential referred pain patterns that could originate from either:

1. Primary testicular/scrotal pathology with referred back pain
2. Lumbar spine pathology with referred pain to the testicle
3. Retroperitoneal or abdominal pathology affecting both areas

Several case reports document the relationship between lumbar disc pathology and testicular pain 2, 3. In one case, a patient with a 3-year history of low back pain and 2 years of unexplained testicular pain was found to have disc protrusions at L1/L2, L3/L4, and L4/L5 2. Another case described a patient with a 5-year history of testicular pain related to thoracolumbar dysfunction with a central disc protrusion at T12-L1 3.

Follow-up Imaging Considerations

If initial imaging is inconclusive, consider:

MRI Lumbar Spine Without Contrast

• Indicated if X-rays are negative but clinical suspicion for disc pathology remains high
• The ACR rates MRI spine without IV contrast as "usually appropriate" (8/9) for back pain with radicular symptoms 1
• Superior for evaluating:
  • Disc herniations
  • Nerve root compression
  • Spinal stenosis
  • Inflammatory conditions

MRI Pelvis (Scrotum)

• Consider if ultrasound findings are equivocal
• May provide additional information for complex cases
• Not recommended as initial imaging 1

Clinical Pearls and Pitfalls

• Pitfall: Focusing only on back pathology and missing testicular pathology (or vice versa)
• Pitfall: Assuming testicular pain with back pain is always musculoskeletal in origin
• Pearl: Thoracolumbar nerve root irritation (T10-L1) can cause referred testicular pain 3
• Pearl: Successful treatment of lumbar disc pathology has been documented to resolve testicular pain in case reports 4, 2
• Pearl: Chronic testicular pain may have multiple contributing factors requiring comprehensive evaluation

Special Considerations

• In this 64-year-old veteran with worsening symptoms and prior ER visit, consider the possibility of serious pathology requiring urgent intervention
• Age and risk factors increase concern for malignancy, vascular pathology, or infection
• The radiation of pain from back to testicle suggests a potential neurological component that warrants thorough evaluation

By following this imaging approach, you will be able to comprehensively evaluate both potential urological and spinal causes of the patient's symptoms, leading to appropriate diagnosis and management.