Case Report: Acute Testicular Pain as the Initial Manifestation of a Ruptured Common Iliac Artery Aneurysm

Background and Clinical Significance: Ruptured common iliac artery aneurysms may mimic urological disease, particularly when retroperitoneal bleeding causes ureteral compression and secondary hydronephrosis. This case is clinically relevant because the first symptom was acute stabbing testicular pain, followed by lumbar discomfort and ultrasound findings suggestive of obstructive uropathy. Case Presentation: A 73-year-old man with arterial hypertension and active smoking presented to the Emergency Department with sudden left lumbar pain that initially radiated to, or was perceived in, the left testicle. The testicular pain resolved spontaneously, but persistent poorly localized lumbar pain continued. He was afebrile and initially hemodynamically stable. Point-of-care ultrasound showed left hydronephrosis, while the abdominal aorta appeared unremarkable. Because the patient looked clinically unwell and the abrupt, stabbing onset was not fully explained by uncomplicated renal colic, contrast-enhanced abdominal and pelvic computed tomography was performed. CT revealed a fissured saccular aneurysm of the left common iliac artery with active contrast extravasation and a large retroperitoneal hematoma compressing the ipsilateral ureter, thereby causing secondary hydronephrosis. The patient underwent urgent endovascular treatment with percutaneous transluminal angioplasty and Bentley stent. Post-revascularization CT showed no further contrast extravasation, and the patient was discharged after seven days without complications. Conclusions: In older patients with cardiovascular risk factors, sudden testicular, flank, or lumbar pain may warrant consideration of retroperitoneal vascular emergencies, even when initial ultrasound suggests a urological diagnosis. In this patient, discordance between the clinical presentation and the initial ultrasound findings prompted contrast-enhanced CT, which enabled diagnosis and timely vascular management.