What is the best approach for a male patient with intermittent, dull, achy left testicular pain, hypertension (elevated blood pressure), and a history of resolved enlarged bladder, who is taking magnesium (Mg), glucosamine, folic acid, vitamin D, vitamin C, and a multivitamin daily, and magnesium citrate?

Approach to Intermittent Left Testicular Pain in a Monogamous Male

This patient's presentation—intermittent, dull, positional testicular pain without red flags—most likely represents chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) or musculoskeletal referred pain, and should be managed conservatively with pelvic floor physical therapy, lifestyle modifications, and reassurance after ruling out serious pathology. 1, 2

Initial Diagnostic Evaluation

Rule Out Emergent Conditions First

• Testicular torsion is excluded by the 3-week duration, intermittent nature, and lack of acute severe pain—torsion presents with sudden, severe, constant pain requiring emergency intervention 3
• Infection/epididymitis is unlikely given absence of fever, dysuria, penile discharge, or urinary symptoms, and monogamous relationship status 1
• Testicular cancer screening is warranted given the chronic nature—perform careful physical examination for masses, asymmetry, or firmness 4

Physical Examination Priorities

• Palpate for testicular masses, epididymal tenderness, or varicocele (dilated veins that feel like "bag of worms") 5
• Assess for pelvic floor muscle tenderness via digital rectal examination 2
• Evaluate sacroiliac joint and hip mechanics, as dysfunction can cause referred testicular pain via pudendal nerve compression 6, 7
• Check cremasteric reflex (should be present bilaterally) 3

Laboratory and Imaging

• Urinalysis and urine culture to definitively exclude occult infection 1
• Scrotal ultrasound is NOT routinely indicated unless physical exam reveals a mass, significant asymmetry, or findings suggestive of structural pathology 4
• Ultrasound may detect varicocele if palpation is equivocal, though clinical examination is usually sufficient 4

Most Likely Diagnosis: CP/CPPS

Clinical Features Supporting This Diagnosis

• Pain characteristics match CP/CPPS perfectly: dull, achy pain in the testicular region lasting minutes to hours, worsened by prolonged sitting 1, 2
• Positional relief (improved with position changes) suggests musculoskeletal or pelvic floor muscle involvement 2, 7
• Absence of urinary symptoms does not exclude CP/CPPS—many patients have pain-predominant phenotype without significant voiding complaints 1, 2
• The American Urological Association defines CP/CPPS as pelvic pain or discomfort for at least 3 months localized to perineum, suprapubic region, testicles, or tip of penis, often exacerbated by sitting 1, 2

Overlapping Condition to Consider

• Interstitial cystitis/bladder pain syndrome (IC/BPS) has nearly identical presentation to CP/CPPS in men, and some patients meet criteria for both conditions 1, 8, 2
• His history of "enlarged bladder" (possibly IC/BPS or bladder outlet obstruction) that resolved may be relevant 8

Recommended Treatment Approach

First-Line Conservative Management

• Manual pelvic floor physical therapy targeting trigger points, muscle contractures, and pelvic floor tension—this is the most evidence-based intervention 2
• Stress management techniques including meditation and imagery to manage symptom exacerbations 2
• Lifestyle modifications: avoid prolonged sitting, use cushioned seating, wear loose-fitting underwear (already doing this) 2
• Iliopsoas stretching and sacroiliac joint mobilization if musculoskeletal examination reveals dysfunction 6, 7

Pharmacologic Options if Conservative Measures Insufficient

• Amitriptyline 10 mg at bedtime, titrated gradually to 75-100 mg if tolerated, for neuropathic pain component 8, 2
• Multimodal pain management with non-opioid alternatives preferred; avoid opioids 8, 2

When to Consider Varicocelectomy

• If physical examination reveals clinically palpable varicocele (grade 2-3), microsurgical varicocelectomy resolves pain in approximately 80% of carefully selected cases 5
• Predictors of success include palpable varicocele, failed conservative management, and dull/aching pain character 5
• Do not pursue surgery without clear structural abnormality—outcomes are poor when performed for pain alone without identifiable pathology 9

Address the Hypertension

• Elevated blood pressure requires separate evaluation with home monitoring as planned [@patient presentation@]
• Some antihypertensive medications (particularly beta-blockers) can affect sexual function, though not typically causing testicular pain 4

Medication Review

Magnesium Citrate Consideration

• Magnesium citrate is a laxative and should not be used chronically without indication 10
• The FDA label warns against use for longer than 1 week without medical supervision 10
• Recommend discontinuation unless he has documented chronic constipation requiring ongoing laxative therapy 10
• Chronic laxative use can cause electrolyte imbalances and dependency 10

Other Supplements

• Glucosamine, folic acid, vitamin D, vitamin C, and multivitamin are unlikely to contribute to testicular pain [@patient presentation@]

Critical Pitfalls to Avoid

• Do not dismiss as purely psychological—CP/CPPS has real neuromuscular and inflammatory components requiring physical treatment 2
• Do not perform orchiectomy for chronic pain without exhausting all conservative and minimally invasive options—pain resolution is not guaranteed and may worsen 9
• Do not order extensive imaging (CT, MRI) without specific clinical indication—this leads to incidental findings requiring unnecessary follow-up 4
• Do not treat empirically with antibiotics in absence of infection evidence—this is ineffective for CP/CPPS and promotes resistance 1
• Recognize that "pressure" rather than "pain" is common in CP/CPPS and IC/BPS—do not dismiss these descriptors 1, 8

Follow-Up Strategy

• Reassess in 4-6 weeks after initiating pelvic floor physical therapy 2
• If symptoms persist or worsen despite conservative management, consider referral to urologist with expertise in chronic pelvic pain 2
• Annual testicular self-examination given slightly elevated cancer risk in men with chronic testicular symptoms 4