A 45‐year‐old man with flank pain and inability to ejaculate

Abstract

A 45-year-old man with left-sided flank pain and difficulty ejaculating. History of the Present IllnessThe patient developed left-sided flank pain in April 2010. He was evaluated in the emergency department when the pain had persisted for 3 weeks. He reported worsening of the pain in the evening and difficulty with ejaculation since the pain began: "I get a knot in my side," then "I can't ejaculate." He also reported associated low back pain and increased pain with bending to his left. His general physical examination was unremarkable. Urine analysis demonstrated 30 mg/dl protein, 10 mg/dl ketones, 8 mg/dl urobilinogen (reference value Ͻ2.0), 8 red blood cells/ high-power field (hpf), 2 white blood cells/hpf, and mucous. He was prescribed ibuprofen for abdominal pain and was advised to follow up with his primary care provider.The pain persisted. He saw his primary provider in July with worsening epigastric and left-sided abdominal and flank pain. By this time, he had decreased appetite, early satiety, and weight loss of 22 pounds. His primary provider ordered a computed tomographic (CT) scan of his abdomen and pelvis, which demonstrated a rind of soft tissue in the retroperitoneum surrounding the aorta and inferior vena cava and wall thickening of the sigmoid colon and rectum. A biopsy of the mass was done by interventional radiology at another hospital. Since his pain was unrelieved by acetaminophen/hydrocodone, he was admitted to our hospital for further evaluation and pain control. He did not know the results of the biopsy. Medical HistoryHe had been relatively healthy prior to the onset of illness in April. Atheromatous calcification of the aorta with mild ectasia inferiorly measuring up to 2.3 cm in diameter was noted incidentally on a CT scan obtained to evaluate for ureteral calculi in September 2008. He had a remote history of gonorrhea and chlamydia infections, which were treated. He had been seen in the emergency department for right testicular pain following trauma at age 35 years and left testicular pain without clear etiology at ages 40 and 43 years. The first episode of left testicular pain was attributed to epididymitis. The second was attributed to suspected passage of a ureteral calculus. Social and Family HistoryThe patient's family history was negative for rheumatic disorders. Several family members, including his mother, had diabetes mellitus and hypertension. His sister had thyroid disease. He was unemployed, but previously worked as a baker. He smoked one-quarter of a pack of cigarettes per day for several years, and previously smoked marijuana. He consumed, on average, 1 alcoholic beverage per week and denied intravenous drug use. He was sexually active and did not consistently use barrier protection. Review of SystemsThe patient reported persistent inability to ejaculate, without decrease in arousal or orgasm and without associated pain. He also reported low back pain that preceded his current illness by years. He had constipation for 2 weeks.