Can appendicitis radiate pain to the testicle?

Can Appendicitis Pain Radiate to the Testicle?

Yes, appendicitis pain can radiate to the testicle, though this is an atypical presentation that may lead to diagnostic confusion with primary testicular conditions.

Mechanism and Clinical Significance

Appendicitis typically presents with periumbilical pain that migrates to the right lower quadrant, but in some cases, the pain can radiate to the testicle due to:

• Shared nerve pathways between the appendix and testicle
• Inflammation extending through a patent processus vaginalis
• Secondary inflammation of nearby structures

Evidence for Testicular Pain in Appendicitis

Several case reports document appendicitis presenting with testicular pain:

• A case of a 19-year-old male with suppurative appendicitis presenting primarily with scrotal pain 1
• A 12-year-old patient with perforated appendicitis presenting with left inguinal and testicular pain 2
• A 57-year-old patient with secondary appendicitis related to an undescended testicle 3

Diagnostic Approach for Patients with Testicular Pain

When a patient presents with testicular pain, it's crucial to:

1. Rule out testicular torsion first - This is a surgical emergency requiring immediate intervention within 6-8 hours to prevent testicular loss 4, 5

   • Ultrasound with duplex Doppler is the initial diagnostic test of choice
   • Normal intratesticular vascularity effectively rules out torsion 5

2. Consider appendicitis in the differential diagnosis when:

   • Pain extends beyond the testicle to the right lower quadrant
   • Systemic symptoms like fever, nausea, vomiting are present
   • Laboratory findings show leukocytosis
   • Testicular ultrasound is normal

Imaging Recommendations

For suspected appendicitis with testicular pain:

1. Initial imaging: Ultrasound of the scrotum to rule out testicular torsion and other testicular pathologies 4, 5

2. If testicular pathology is ruled out:

   • CT abdomen and pelvis with IV contrast is usually appropriate for adults with suspected appendicitis 4
   • Ultrasound of the abdomen is the preferred initial imaging for children with suspected appendicitis 4
   • MRI abdomen and pelvis without IV contrast is recommended for pregnant patients 4

Clinical Pearls and Pitfalls

• Don't miss torsion: Testicular torsion presents with sudden severe pain, high-riding testicle, and absent blood flow on ultrasound 5
• Consider atypical presentations: Appendicitis can present with referred pain to unusual locations, including the testicle
• Avoid diagnostic delays: When appendicitis presents with testicular pain, misdiagnosis can lead to delayed treatment and increased risk of perforation
• Interdisciplinary approach: Collaboration between urology and general surgery may be necessary in cases with overlapping symptoms 1

Management

If appendicitis is confirmed:

• Laparoscopic appendectomy remains the standard treatment for most cases 6
• Antibiotics-first approach may be considered in uncomplicated appendicitis without high-risk CT findings 6

If testicular pathology is confirmed:

• Management depends on the specific diagnosis (torsion, epididymitis, etc.) 5

The key to successful management is recognizing that appendicitis can present atypically with testicular pain, and maintaining a high index of suspicion when evaluating patients with scrotal pain.