BACKGROUND

Ruptured abdominal aortic aneurysm ((R)AAA) is a life-threatening condition with a mortality rate approaching 90%1 with greater than 44% prehospital mortality. Of those that make it to the hospital, emergency surgery still has a mortality rate of 50%.1 Ruptured AAA can prove difficult to diagnose, especially when not suspected. The classical presentation includes a pulsatile mass in the abdomen, back pain and episodes of haemodynamic instability. Other common presentations include loin pain and mass in the abdomen.2 We report a rare case of ruptured AAA where the patient presented with right testicular pain and diagnosis was only made on kidney, ureter and bladder CT scan.

CASE PRESENTATION

A 70-year-old man was referred to the urologist with a diagnosis of right testicular torsion. He presented after midnight with sudden onset severe right-sided testicular pain. The pain started suddenly, sharp in nature, radiating to the groin. There was no history of trauma and he denied any urinary symptoms. His past medical history included asbestosis, hypertension and anxiety. He had a vasectomy in 1976. Medications included bisoprolol, doxazocin and antidepressants. He was a smoker of one packet of cigarettes per day, with minimal alcohol consumption, and lived with his wife.

On examination he was afebrile, pulse 80 beats/min, blood pressure 120/70 with a haemoglobin level of 14.2 mg/dl on admission. The patient had a Body Mass Index (BMI) of 40. Abdominal examination did not reveal any obvious mass; groin examination revealed a very tender swollen right testicle and a normal left side. During the period of examination the patient developed a right-sided loin pain and was unable to lie still. A diagnosis of ureteric colic was suspected and a kidney, ureter and bladder CT scan arranged. At this stage the patient was haemodynamically stable. A CT scan showed a leaking AAA (fig 1).

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Figure 1

Kidney, ureter and bladder CT scan of the patient’s abdominal aortic aneurysm (AAA).

INVESTIGATIONS

Kidney, ureter and bladder CT scan showing a 6.5 cm infrarenal aneurysm.

TREATMENT

Aneurysmal repair.

OUTCOME AND FOLLOW-UP

A vascular surgeon was contacted and the patient taken to theatre. In theatre, a posterior leak from a 6.5 cm ruptured infrarenal fusiform abdominal aortic aneurysm was confirmed. The AAA was repaired successfully and the patient made a good recovery. The patient spent 48 h in the intensive care unit and was discharged home after 2 weeks in hospital

DISCUSSION

An aortic aneurysm is a thin, weakened section of the wall of the aorta that bulges outward; rupture of the aneurysm is a life-threatening condition. Many patients do not make it to the hospital. Of those that do reach the hospital, prompt diagnosis and emergency surgery is the only option. Delay in diagnosis often contributes to the already high mortality rate. Ruptured AAA can present or mimic a variety of cases, such as renal colic, diverticulitis, acute myocardial infarction, backache, sepsis,1 buttock pain,3 appendicitis,4 strangulated inguinal hernia2 and testicular pain.5

Establishing a diagnosis of RAAA requires a high index of suspicion, especially in older patients with risk factors for cardiovascular disease. These include smoking, diabetes, hypertension and hypercholesterolaemia.

The classical presentation includes an older man with a history of collapse associated with abdominal, flank or back pain. Examination reveals an expansile, pulsatile mass with haemodynamic instability. In a patient who is deemed fit for aneurysm repair, the management is immediate resuscitation and an exploratory laparotomy with aneurysmal repair. In those who present with more subtle signs, difficult clinical examination (due to obesity) or atypical presentations, a contrast CT scan should be performed if the patient is stable. An ultrasound scan is safer and quicker to perform, but is very operator dependant and can be difficult in a patient who is obese. Additionally, it usually only confirms the presence of an aneurysm but often cannot rule out a leak. In general, there should be a low threshold for imaging in an older haemodynamically stable patient with suggestive symptoms and signs to exclude a ruptured aneurysm.

Ruptured AAA presenting with acute testicular pain is extremely rare. There are less than 10 cases reported in the literature. Isolated sudden onset right testicular pain is even more rare. The aetiology behind the symptom is unclear. It is thought that the developing expansion, prior to rupture, or the developing haematoma around the visceral nerves from the testes in the lumbar region is responsible for this symptom.5 Compression of the ilioinguinal nerve or the genitofemoral nerve as it courses through the psoas muscle has been suggested as an explanation for the testicular pain.6