Referred pain is felt at a location distant from the diseased organ. Like visceral pain and in contrast to parietal pain, referred pain produces symptoms, not signs. Unlike visceral pain, referred pain is usually ipsilateral to the involved organ and is felt in the midline only if the pathologic process is also located in the midline. This is because referred pain, in contrast to visceral pain, is not mediated by fibers providing bilateral innervation to the cord. Like those of visceral pain, patterns of referred pain are based upon developmental embryology. For example, the ureter and the testes share the same segmental innervation because these structures were once anatomically contiguous. Both therefore supply afferent fibers to the same lower thoracic and upper lumbar segments of the spinal cord. Thus, acute ureteral obstruction is often associated with ipsilateral testicular pain. Other sites of referred pain reflect similar dermatomal sharing, providing explanations for otherwise puzzling associations between supra- or subdiaphragmatic irritation and ipsilateral supraclavicular/shoulder pain; gynecologic pathology and back/proximal lower extremity pain; biliary tract disease and right infrascapular pain; and myocardial ischemia and midepigastric/neck/jaw/upper extremity pain.
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