Differential Diagnosis for Testicular Pain

The patient's presentation of sudden, severe testicular pain radiating to the pubic area and rectum, accompanied by a feeling of passing out, suggests a few possible diagnoses. Here's a categorized list of potential causes:

• Single most likely diagnosis

  • Testicular torsion: This condition is characterized by the twisting of the spermatic cord, cutting off the blood supply to the testicle. The sudden onset of severe pain, radiation to the pubic area and rectum, and the feeling of passing out (possibly due to pain severity) are consistent with testicular torsion. The lack of swelling or ecchymosis does not rule out this diagnosis, as these signs may not always be present early on.

• Other Likely diagnoses

  • Epididymitis: Inflammation of the epididymis, which can cause severe testicular pain that may radiate. However, epididymitis typically presents with more gradual onset and may be accompanied by signs of infection such as fever or urinary symptoms.
  • Spermatic cord torsion (or epididymal torsion): Similar to testicular torsion but involves the twisting of the spermatic cord at the level of the epididymis. Symptoms can be very similar to testicular torsion.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Testicular rupture: Although less common, a rupture could present with sudden severe pain and might not always have immediate swelling or ecchymosis. It's crucial to consider this diagnosis due to the potential for severe complications if not promptly treated.
  • Appendicitis: While the primary symptom of appendicitis is abdominal pain, in some cases, especially if the appendix is located near the rectum (retrocecal appendix), pain can radiate to the testicles. The feeling of passing out could be due to severe pain or other associated symptoms like nausea and vomiting.

• Rare diagnoses

  • Varicocele thrombosis: A varicocele is an enlargement of the veins within the scrotum, similar to varicose veins. Thrombosis (clotting) within a varicocele could potentially cause sudden pain, though this would be less common and might be accompanied by a palpable mass.
  • Henoch-Schönlein purpura (HSP): A form of vasculitis that can affect various parts of the body, including the testicles, causing pain. However, HSP typically presents with purpura (rash), arthritis, and gastrointestinal symptoms, making it less likely in this scenario without additional symptoms.