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13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
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183
Brian Nguyen
Brian Nguyen is a 23-year-old student with the chief complaint of,
“Something is stabbing my left nut
and I’m peeing blood.” Brian stated
that he was awakened from a sound
sleepwiththeworstpainhehad
ever experienced. He stated that it
was worse than the time he broke
his leg when he tripped over a curb.
“Doctor, please h elp me! Give me
something for the pain. I can’ttakemuchmore!” begged Brian. With every
paroxysm of pain, B rian closed his eyes, whimpered, and paced the exam
room. It was obvious he was in a lot of pain. Brian said that the pain would
come out of nowhere, like someone kicked him in the nuts, and then it went
away as quickly as it came. “ Doctor, the pain hits and it doubles me over.”
Brian went on to say that he felt like he had to pee every 4 or 5 minutes, but
when he tried to pee, he had to really strain to get any p ee out. And when it
came out, it was bloody. “ Doctor, please help me. I’mafraidthatIwillbleed
to death. Do you think I have cancer?” Brian said he felt like he needed to
throw u p but was afraid to because he thought it would make the pain worse.
I asked, “Brian, is the pain on both sides or just on one side?” He responded,
“It’salwaysinmyleftnutandupbymykidney.It’s never on the right.” Brian
went on to say that he had tried extra-strength Tylenol, but the pain just continued to get worse. I asked Brian if he ever had anything like this happen
before, and he shook his head no. I asked what made it better, and he said
nothing. He thought that moving around helped a little, but that nothing he
has tried has really worked. Brian denied any fever or chills, but volunteered
that he felt horrible.
On physical examination, Brian was afebrile. His respirations were 18, and
hispulsewas88andregular.Hisbloodpressurewas158/88.Icheckedfor
costovertebral angle (CVA) tenderness, and when I percussed his left CVA
area, Brian immediately cried out in pain and came off the exam table. He
whimpered in pain and said, “Doctor, I’m begging you, warn me when you
are going to do that again. It’s really bad, and I need to have something to hold
on to.”
WhenItoldBrianIwantedtoexaminehistesticles,hegotreallyupset.
“Doctor, I’ m begging you, please put me out before you do! I just don’t
knowhowmuchmoreofthispainIcantake.It’s horrible, worse than any-
thing you can imagine. I did not know that anything could hurt this bad!” I
said, “Le t’ s start with the right testicle, Brian, and go from there. How about
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13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
that?” Brian was reluctant, but said, “Do what you have to do, Doc. I have
to get rid of this pain o r I am done for. I am afraid of what I might do if this
pain continues. I don’t think I can take much more. Doctor, let me ask you
something. What did I do to deserve this? I try to do good!” His right testicle exam was normal, and with great convincing, I got a quick look and feel
of his left testicle, which appeared and felt completely normal. There was
minimal pain with palpation. Brian was a little tender over his bladder, but
I felt no abnormal mass. His fundoscopic examination was normal, as was
the rest of his head, eyes, ears, nose, throat (HEENT ) exam. His cardiopulmonary examination and thyroid were normal. His abdominal examination
revealed no abnormal mass or organomegaly. There was no peripheral
edema.
IaskedBriantopointwithonefingertoshowmewhereithurtthemost,
and with great care to avoid touching his groin, he pointed to his left testicle.
“Doctor, the pain starts way down deep in my left nut, way down deep and it
shoots up into the tip of my penis.” I told Brian that I was pretty sure that I
knew what was going on and t hat we had a lot of treatment options to get on
top of this pain. Brian replied, “I hope to h ell you know what you are talking
about, but first I really, really, really have to pee.” Ihandedhimaspecimen
cup. Brian limped off to the bathroom, and a few minutes later he returned
and handed me his cup, which was full of blood.
Key Clinical Points—What’s Important and What’s Not
THE HISTORY
’
No history of previous testicular pain or hematuria
’
No fever or chills
’
Recent onset of severe unilateral testicular pain with associated hematuria
’
Urinary frequency, urgency, and stranguria
’
Onset to peak of the pain is immediate
’
Pain is episodic, with pain-free periods
’
High degree of anxiety regarding pain and associated hematuria
THE PHYSICAL EXAMINATION
’
Patient is afebrile
’
Severe left CVA tenderness
’
Testicular examination is normal
’
Tenderness over bladder
’
Urine with gross hematuria
13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
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OTHER FINDINGS OF NOTE
’
Normal cardiovascular examination
’
Normal pulmonary examination
’
Normal abdominal examination
’
No peripheral edema
’
Normal neurologic examination, motor and sensory examination
’
No pathologic reflexes
What Tests Would You Like to Order?
The following tests were ordered:
’
Dual-energy noncontrast abdominopelvic computed tomography (CT) to
identify the location of the suspected kidney stone and to try and
characterize its composition
’
Urinalysis to identify the presence of blood, crystals, and bacteria and
urinary pH (as a pH .7 suggests the presence of urea-splitting organisms
such as Proteus, Pseudomonas, or Klebsiella bacteria, and/or the presence
of struvite stones). A urine pH of less than 5 points the clinician toward the
consideration of uric acid stones.
’
Comprehensive metabolic panel, including serum creatinine and uric acid
determinations, to clarify renal function and to identify the presence of
hyperuricemia.
’
Complete blood count (CBC) to rule out anemia of chronic disease and to
identify leukocytosis associated with urosepsis.
185
TEST RESULTS
Dual-energy noncontrast abdominopelvic CT revealed a large stone in the left
upper kidney, which was characterized as uric acid in composition (Fig. 13.1).
Urinalysis revealed gross hematuria. Uric acid crystals were also identified.
No nitrates were identified on the dipstick, and the pH was 5.2.
Comprehensive metabolic panel was normal other than a markedly elevated
uric acid.
CBC revealed a hemoglobin of 15.4 and a white count of 10,200 with a slight
left shift.
Clinical Correlation—Putting It All Together
What is the diagnosis?
’
Nephrolithiasis (uric acid stone)
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13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
Fig. 13.1 Characterization of kidney stones using dual-energy computed tomography (DECT). Axial
noncontrast CT image (a) shows a calculus at the upper pole region of left kidney. Postprocessed
color map (b) shows a calcium-containing calculus in the left kidney, colored in blue. DE plot (c) confirms
the composition of the stone (arrow) is uric acid, helping guide subsequent preventative treatment.
(From McCarthy CJ, Baliyan V, Kordbacheh H, et al. Radiology of renal stone disease. Int J Surg.
2016;36(part D):638646 [Fig. 4]. ISSN 17439191, https://doi.org/10.1016/j.ijsu.2016.10.045, http://
www.sciencedirect.com/science/article/pii/S1743919116310044
.)
13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
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187
The Science Behind the Diagnosis
ANATOMY OF THE URINARY TRACT
The upper urinary tract is comprised of the pelvicalyceal system of the kidney
and the ureter (Fig. 13.2). The lower urinary tract is comprised of the bladder and
urethra. The kidneys lie in the retroperitoneal space at the level of the 12th thoracic vertebra. Due to the liver, the right kidney lies slightly lower than the position of the left kidney. The ureter emerges from the hilum of the kidney and runs
in a straight trajectory vertically downward within the retroperitoneal space,
lying on top of the psoas major muscle. Each ureter connects its respective kidney with the urinary bladder. There are significant differences in topographic
relationships of the ureter in males versus females, specifically the presence of
the uterine artery in females and the vas deferens in males (
CLINICAL CONSIDERATIONS
Nephrolithiasis, also known as renal calculi and kidney stones, is the stonelike
deposit of acid salts and minerals that forms within the kidneys when these substances exist in concentrations above the saturation point within the urine. This
disease occurs more commonly in males and peaks between the ages of 30 and
50 years. Nephrolithiasis occurs more commonly in Whites than in Hispanics
and is much less common in Blacks. There is a family clustering of nephrolithiasis. Men have a family history of kidney stones with a two to three times greater
probability of suffering from this disease.
Variables that encourage the formation of renal calculi include the presence of
red blood cells, urinary casts, low calcium diets, diets high in high-fructose corn
syrup and sodium, and other crystals that can form as a nucleating nidus that
may promote stone formation. Ambient temperature may also correlate with the
increased formation of stones, with a seasonal predilection for stone formation in
the warmer southeast United States during the summer months, and in occupations exposed to high ambient temperatures (e.g., military deployments to hot
desert climates). Urinary tract abnormalities such as horsesho e kidney may also
increase the risk of nephrolithiasis. Some investigators believe that the obesitymetabolic syndrome-diabetes spectrum is also a risk factor for nephrolithiasis.
The solubility of stone-forming solutes can also be inhibited by the presence of
citrate, glycoproteins, and magnesium. The pH of the urine can increase or
decrease the incidence of renal calculi, depending on which type of kidney stone
is being formed, with acidic pH encouraging calcium-based stone formation.
Renal calculi are most commonly calcium based, with calcium oxalatecontaining stones accounting for approximately 60% to 70% of stones (
Calcium oxalate stones are seen in patients suffering from hyperparathyroidism,
malabsorption post bariatric surgery, hypervitaminosis D, diets high in
Fig. 13.3).
Fig. 13.4).
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Fig. 13.2 The topographic relationships of the kidneys, ureters, and suprarenals. (From Mahadevan V. Anatomy of the kidney and ureter. Surgery (Oxford). 2019;37(7):
359364 [Fig. 1]. ISSN 0263-9319,
https://doi.org/10.1016/j.mpsur.2019.04.005, http://www.sciencedirect.com/science/article/pii/S0263931919300924.)
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Fig. 13.3 The relationship of the intrapelvic portion of the ureter as it attaches to the bladder. Note the difference in topographic relationships of the ureterin
males (a) versus females (b), specifically the location of the uterine artery in females and the vas deferens in males. (From Mahadevan V. Anatomy of the kidney
and ureter. Surgery (Oxford). 2019;37(7):359364. ISSN 0263-9319, https://doi.org/10.1016/j.mpsur.2019.04.005, http://www.sciencedirect.com/science/article/
pii/S0263931919300924
.)
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13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
Types of kidney stones
Struvite, 22%
Cystine,
2%
Calcium oxalate,
26%
Fig. 13.4 The composition of kidney stones.
Uric acid, 5%
Calcium phosphate,
7%
Calcium oxalate and
calcium phosphate,
37%
high-oxalate foods such as nuts and chocolate, and in patients with chronic pancreatitis. Calcium phosphate stones are associated with hypercalciuria and urinary alkalization secondary to renal tubular acidosis, or the use of topiramate
and carbonic anhydrase inhibitors such as acetazolamide. Much less common
are uric acid stones, whose formation is thought to be associated with excessive
protein intake, gout, low urine output, and acidic urine. Ammonium acid urate
stones and struvite stones are also less common than calcium-containing stones.
Ammonium acid stones are associated with inflammatory bowel disease, laxative abuse, and ileostomy. Struvite stones are most commonly associated with
urinary tract infections with urease-positive bacteria that convert urea to ammonium. Disorders of cystine transport can also cause kidney stones
SIGNS AND SYMPTOMS
Calculi can form in the intraparenchymal space, the calyx, and pelvis of the kidney, as well as the ureter and bladder. Variables, including the size of the calculus, its location, and the patient’s anatomy, will affect its clinical impact and
symptomatology. The symptoms of nephrolithiasis are primarily the result of
increased intraurinary tract pressure, which stretches and stimulates nociceptive
nerve endings in the urothelium. These pain impulses are carried via the afferent
sympathetic and somatic nerves at the T11-L1 levels.
The pain of nephrolithiasis tends to wax and wane and is often colicky in
nature, with spasm of the ureters and bladder occurring as stones pass distally. If
the urinary obstruction is incomplete or intermittent, the pain will tend to wax
13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
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191
BOX 13.1’The Relationship of Kidney Stone Location to the Location of
Perceived Pain and Associated Symptoms
Associated SymptomsLocation of PainLocation of Stone
Ureteropelvic junction Severe deep flank pain,
Ureteral stone
’
’
’
Bladder stone Positional urinary
Urethra Severe localized pain,
suprapubic pain
Pain radiates to flankUpper ureter
and lumbar areas
Pain radiates anteriorlyMiddle ureter
and caudally
Pain radiates into groinDistal ureter
or testicle (men) or labia
majora (women)
retention, minimal to no
pain
urinary obstruction
Urinary frequency/urgency, dysuria,
stranguria, hematuria
Intense nausea with or without
vomiting, hematuria
Intense nausea with or without
vomiting, diaphoresis, hematuria
Intense nausea with or without
vomiting, diaphoresis, hematuria
Rarely, sensation of bladder fullness,
hematuria
Deep nausea with or without
vomiting, hematuria
and wane, with complete obstruction causing constant, severe pain. Pain may be
referred to the flank, groin, testicle, or labia, with the location of the pain often
reflecting the anatomic location at which the stone is obstructing the urinary sys-
Box 13.1). Nausea and vomiting are frequently present, as is hematuria
tem (
(Fig. 13.5). Urinary urgency, frequency, dysuria, and meatal pain are also common. The patient suffering from acute kidney stones may find it difficult to find
a comfortable position and may pace the floor. Fever, rigors, and chills in
patients with signs and symptoms thought to be caused by kidney stones are
serious findings, and immediate culture of urine and any retrieved calculi should
be obtained and appropriate antibiotic therapy instituted. Anxiety and tachycardia and associated hypertension are often present.
Finding on physical examination of the patient suffering from the acute pain
of nephrolithiasis includes diaphoresis, tachycardia, and hypertension.
Costovertebral angle tenderness is invariably present, as is the absence of
abdominal and genital findings. A commonly used diagnostic rubric to increase
the specificity of diagnosis of renal calculi is the STONE score (Box 13.2). STONE
is an acronym that allows easy scoring to determine the likelihood that a patient
is suffering from renal and/or ureteral calculi. A score greater than 13 provides
diagnostic accuracy approaching 90%.
TESTING
Unless there is significant dehydration or compromise of renal function secondary to obstruction, the serum creatinine and serum chemistry will be within
normal limits, although careful attention to serum calcium levels i s mandatory
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13—A 23 YEAR-OLD WITH SEVERE TESTICULAR PAIN AND HEMATURIA
Fig. 13.5 The pain location often reflects the anatomic site at which the stone is obstructing the urinary
system. Associated symptoms include nausea and vomiting, tachycardia, anxiety, and hypertension.
(From Waldman S. Atlas of Common Pain Syndromes. ed. 4. Philadelphia: Elsevier; 2019 [Fig. 72-2].)
to help identify patients suffering from hyperparathyroidism. Leukocytosis
with a left shift secondary to the stress of the pain may also be present. On urinalysis, microscopic hematuria is common, with some patients experiencing
gross hematuria. Crystalluria may be observed on microscopic evaluation
(Fig. 13.6). Leukouria and the presence of nitrates and leukocyte esterase in the
urine is highly suggestive of a urinary tract infection. Strained urine may reveal
renal calculi (Fig. 13.7).
Noncontrast, low-dose CT scans of the urinary tract have replaced intrave-
nous pyelography as the first step in the diagnosis of nephrolithiasis (Fig. 13.8).
CT scan not only provides important information as to the location and shape of
the stone and the nature of obstruction but can also identify anatomic abnormalities of the urinary tract that may complicate surgical interventions (
Fig. 13.9).
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