Differential Diagnosis for Testicular Pain

The patient presents with testicular pain that originated in the tailbone, moved to rectal pain, and then radiated to the testicles. The pain has not been relieved by over-the-counter (OTC) pain medications but showed short-term improvement with Tramadol. Here is a differential diagnosis organized into categories:

• Single Most Likely Diagnosis

  • Musculoskeletal Pain or Strain: Given the initial location of pain in the tailbone and its radiation to the rectal area and then the testicles, a musculoskeletal issue such as a strain or pain referred from the lower back or pelvic muscles is a plausible explanation. The temporary relief with Tramadol, a stronger pain medication, supports this possibility.

• Other Likely Diagnoses

  • Prostatitis: Inflammation of the prostate gland can cause pain in the pelvic area, rectum, and testicles. The fact that OTC pain medications did not provide relief but Tramadol did might suggest a more severe inflammatory process.
  • Epididymitis: Inflammation of the epididymis, a tube at the back of the testicle that stores and carries sperm, can cause testicular pain that may radiate from the lower back or pelvic area.
  • Ureteral Stone: A stone in the ureter can cause severe pain (renal colic) that may start in the back and radiate to the groin or testicles. However, the lack of specific mention of flank pain or other urinary symptoms makes this less likely.

• Do Not Miss Diagnoses

  • Testicular Torsion: Although the pain pattern is atypical for testicular torsion (which usually presents acutely and is extremely painful), this is a medical emergency that requires immediate attention. Delay in diagnosis can lead to loss of the testicle.
  • Appendicitis: While less common, appendicitis can present with atypical pain patterns, especially if the appendix is retrocecal (located behind the cecum). Severe abdominal or pelvic pain that does not improve with pain medication is a red flag.
  • Kidney Stone with Obstruction: Similar to ureteral stones, but with potential for more severe consequences if there's an obstruction leading to kidney damage.

• Rare Diagnoses

  • Referred Pain from Other Sources: Rarely, pain from other areas like the abdomen or even from conditions like herpes zoster (shingles) can be referred to the testicles.
  • Testicular Cancer: While testicular cancer can cause aching in the testicle, it is less likely to cause acute, severe pain radiating from the tailbone or rectal area.
  • Inflammatory Bowel Disease: Conditions like Crohn's disease or ulcerative colitis can cause pelvic pain, but the presentation would typically include gastrointestinal symptoms like diarrhea, blood in stool, or weight loss.