History of Present Illness (HPI)

The patient is a male presenting with a 2-week history of right testicular pain. He has been managing the pain with Tylenol but reports it has become increasingly uncomfortable. He has a history of similar pain at ages 17 and 27, for which he underwent ultrasound (u/s) and sexually transmitted infection (STI) testing, all of which were within normal limits (WNL). The patient leads a relatively sedentary lifestyle and does not wear supportive underwear. He denies any discharge.

Differential Diagnosis

• Single Most Likely Diagnosis
  • Chronic Epididymitis: Given the patient's history of recurrent testicular pain and the fact that previous investigations were normal, chronic epididymitis is a plausible diagnosis. The condition can be caused by bacterial or non-bacterial factors and may be exacerbated by a sedentary lifestyle and lack of supportive underwear.
• Other Likely Diagnoses
  • Varicocele: A varicocele is an enlargement of the veins within the scrotum and can cause chronic pain, which might be exacerbated by a sedentary job.
  • Hydrocele: Although less likely to cause pain, a hydrocele (fluid accumulation around a testicle) could potentially cause discomfort, especially if large.
  • Spermatocele: A spermatocele is a cystic structure filled with sperm, which can cause testicular pain and might be considered given the patient's history.
• Do Not Miss Diagnoses
  • Testicular Torsion: Although the patient's pain has been chronic, testicular torsion is a medical emergency that must be ruled out, even if the likelihood is low given the duration of symptoms.
  • Testicular Cancer: While rare, testicular cancer can present with pain and a mass. Given the patient's age and history of similar episodes, it's crucial to consider and rule out this diagnosis.
  • Epididymo-orchitis due to STI: Despite previous negative STI testing, the possibility of a new infection cannot be overlooked, especially if the patient's sexual practices have changed.
• Rare Diagnoses
  • Henoch-Schönlein Purpura (HSP): A systemic vasculitis that can rarely cause testicular pain.
  • Polyarteritis Nodosa (PAN): A systemic vasculitis that can involve the testicles and cause pain, though it is exceedingly rare.
  • Cystic Dysplasia of the Testis: A rare congenital anomaly that could potentially cause testicular pain, though it would likely have been identified in previous evaluations.