Can kidney stone passage cause bilateral testicular pain versus testicular torsion?

Kidney Stone Passage vs Testicular Torsion: Pain Patterns

Kidney stone passage typically causes unilateral pain that may radiate to the groin, while testicular torsion characteristically presents with sudden-onset unilateral testicular pain; bilateral testicular pain is not a typical feature of testicular torsion and would more likely suggest another etiology such as referred pain from kidney stones or urinary tract pathology.

Pain Characteristics and Differential Diagnosis

Testicular Torsion

• Presents with sudden onset unilateral scrotal pain 1, 2
• Often accompanied by nausea and vomiting 2
• Physical exam reveals:
  • High-riding testicle 1, 2
  • Absent cremasteric reflex 1, 2
  • Normal testicular position in intermittent torsion 3
• Pain does not improve with testicular elevation (negative Prehn sign) 4
• Typically affects adolescents and is rare in men >35 years 1
• Represents a true surgical emergency with a 4-8 hour window before permanent ischemic damage 2

Kidney Stone Pain

• Can refer pain to the groin and testicles
• May cause bilateral testicular pain through referred pain pathways
• Usually accompanied by:
  • Flank pain
  • Radiation to groin
  • Hematuria
  • Urinary symptoms (frequency, urgency)
• Pain may fluctuate in intensity as the stone moves

Key Diagnostic Features

For Testicular Torsion:

• Rapid onset of severe unilateral pain 3
• Horizontal lie of testicle highly correlates with bell-clapper deformity 3
• Doppler ultrasound shows decreased or absent blood flow 1, 4
• "Whirlpool sign" on ultrasound (twisted spermatic cord) has 96% sensitivity and 99% specificity 1

For Epididymitis (common differential):

• Gradual onset of pain 1
• Positive Prehn sign (pain relief with elevation) 4
• Present cremasteric reflex 4
• Doppler ultrasound shows increased blood flow 4
• Often associated with urethritis or UTI 1

Critical Diagnostic Approach

1. Bilateral testicular pain:

   • Highly unusual for testicular torsion (which is typically unilateral) 1, 2
   • More consistent with referred pain from kidney stones or other urinary tract pathology
   • Consider urinalysis to check for hematuria and crystals

2. Imaging considerations:

   • Duplex Doppler ultrasound of scrotum is standard for suspected testicular pathology 1
   • Power Doppler is more sensitive for detecting slow flow, especially in prepubertal testes 1
   • If kidney stones are suspected, consider CT scan of abdomen/pelvis

3. Warning signs requiring immediate surgical exploration:

   • Sudden onset of severe unilateral scrotal pain
   • Nausea/vomiting
   • High-riding testicle
   • Absent cremasteric reflex
   • Do not delay for imaging if clinical suspicion is high 2

Management Implications

• Testicular torsion requires immediate surgical exploration and fixation 2
• Delay in treatment may lead to orchiectomy (42% rate in boys undergoing surgery for torsion) 2
• Intermittent testicular torsion can present with recurrent episodes of severe pain with rapid resolution 3
• Kidney stone management focuses on pain control, hydration, and facilitating stone passage

Common Pitfalls to Avoid

1. Assuming bilateral pain excludes serious testicular pathology
2. Delaying surgical exploration for testicular torsion to obtain imaging
3. Failing to consider referred pain from non-scrotal sources
4. Missing intermittent testicular torsion, which can present with recurrent pain episodes 3, 5
5. Confusing epididymitis with testicular torsion (both can cause scrotal pain but have different onset patterns and physical findings) 1

Remember that testicular torsion is a clinical diagnosis, and if suspected based on history and physical examination, immediate surgical exploration is indicated without delay for imaging studies 2.