Case study: An unusual cause of pain in the testicle

A patient presents with slow onset of testicular pain with no obvious cause. Dr Keith Barnard explains

Mr Barnes was 62 years old and an infrequent visitor to the surgery. He was invariably
unkempt because he often slept rough, even though he had a council flat.

The flat was generally in such a mess that his neighbours and the council often complained.
His infrequent visits to me were usually because of the occasional infestation or a persistent cough.

He smoked roll-up cigarettes and was also an alcoholic, although over the past several years he consistently claimed to have stopped his habitual drinking.

On this visit, Mr Barnes complained of pain in his left testicle which he had had for two months. There was no discharge. I persuaded him to climb on to the couch for an examination. He had a swollen left testicle, but it seemed to be only slightly tender.

Signs and symptoms
Swellings within the scrotum are not usually diagnostically challenging, but I could not decide what was going on
here: because it was the testicle and not the epididymis that was involved, an epididymal cyst or a varicocele were ruled out.

There was no inguinal lymphadenopathy.

His symptoms had been developing slowly over a few weeks, so it was not a torsion, and I did not think it might be a hydrocele because it did not transilluminate.

He was not in the common age group for testicular cancer, although the swelling did seem irregular, and he had no urinary symptoms, but I tested his urine anyway and found it clear.

I listened to his chest because he mentioned his cough was still a problem, but that was also clear.

Mr Barnes wanted me to give him a prescription, but I resisted.

There was something not quite right and, given his general unhealthy lifestyle and reluctance to attend, I needed to make sure this was followed up. I spoke to the urology registrar, and he agreed to see my patient at the end of his clinic.

Exploratory operation
When the registrar phoned me to say that an ultrasound did not show any testicular cancer, I thought I had referred unnecessarily.

But far from it — the registrar was actually quite excited.

‘We don’t know what it is, so we are going to do an exploratory operation,’ he said.

Before they operated, the urologists performed intravenous urography. This was completely normal. A chest
X-ray was also clear.

Biopsies were taken during surgery, and histology of the lesion showed destruction of the testicular tissue with granulomas and caseous necrosis.

There was no doubt about the diagnosis: Mr Barnes had tuberculosis. Confirmation
followed later in the form of positive cultures for acid-fast bacilli.

Mr Barnes was started on multiple antituberculous therapy. Although he had some trouble with side-effects, he appeared to stick to his long-term medication.

His swelling resolved. However, he did not change his unsatisfactory living habits, which might have contributed to his susceptibility to TB.

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