Acute Groin pain DDX?

[NYNPMAN]

I work in primary care. A 65 yo man came in with 2 week old acute pain 6/10 to the left groin radiating from the LLQ. He has no significant Hx except for mild HLD, treated with lipitor 20mg (5 years). He denies any lifting or straining precipitating this pain. Some hyper-extension makes the pain worse and the pain is mostly uncomfortable during the day 2/10. A manual exam with cough elicited a positive sign on the left groin and was absent in the right side. He was sent for a Ct abd/pelvis which returned negative findings. What next? Any ideas?

True inguinal/groin pain or LLQ pain? Did you rule out testicular mass/tenderness and muscular strain on your exam? The left hip looked ok on CT?

With a normal CT (I'd again check the left hip for OA on the CT it should be visible) I'd make sure I covered differentials that wouldn't be visualized first: testicular, arthritic, and muscular/soft tissue. Then start thinking about other less likely considerations that CT could miss including bowel (IBD, celiac, mesenteric ischemia), muscoskeletal (piriformis syn, ostetitis pubis, strains), UTI, and and testicular pathology.

[Dodongo, APRN, NP]

You're positive there was no hernia on CT. Testicular etiology? Keep in mind the left testicular vein drains into the left renal vein - is there a varicocele? Iliopsoas bursitis/tendinitis/strain, OA, nephrolithiasis, etc. Lots of odd differentials to include. Boston mentioned a few good ones.