Segmental Infarction of the Testis: A rare complication of acute epididymitis Arif N. Parambath,1 Ahmed J. Omar,2 Shatha A. Al Hilili,3 Adham Darwish4 Abstract Doppler ultrasound of a 31 year old patient presenting with acute scrotal pain showed features of acute epididymitis. Follow up study performed on the third day showed total ischemia of the testis. Repeat scan on the tenth day revealed partially regained flow in the testis with segmental infarction; an unusual complication of acute epididymitis. This was confirmed by orchidectomy and histopathological examination.
From the Department of Emergency Radiology, Hamad Medical Corporation, Doha, Qatar. Received: 18 Jul 2010 Accepted: 14 Aug 2010 Address correspondence and reprint request to: Dr. Arif Nelliyulla Parambath Specialist, Emergency Radiology Hamad Medical Corporation 3050 Doha, Qatar Email: [email protected]
doi:10.5001/omj.2010.95
Introduction
T
esticular ischemia and segmental infarction are rare complications of acute epididymitis. Accurate diagnosis is essential for instituting proper treatment. Doppler ultrasound is an efficient modality for assessing the serial changes in the vascularity of the testis. Lack of symptomatic improvement is a clear justification for perfoming repeat Doppler ultrasound in acute epididymitis.
On the third day after admission, the patient again presented with increased scrotal pain and swelling. A repeat Doppler study showed total ischemia of the testis with slightly increased vascularity, persisting in the epididymis. (Figs. 2 a & b)
a
b
Case Report A 31 year old patient presented to the emergency department with acute scrotal pain, swelling, dysuria and fever. On examination, he had a tender swelling of the right testis with preservation of cremasteric reflex. Laboratory studies were normal except for mild elevation of WBC count. Doppler ultrasound of the scrotum revealed an enlarged epididymis with increased vascularity and minimal peritesticular fluid, consistent with acute epididymitis. The testis showed normal echotexture and vascularity (Figs. 1a, b). The patient was discharged with antibiotic and analgesics.
Figure 2: (a) Absent testicular flow suggestive of testicular ischemia (white arrow). (b) Hypervasular epididymis (black arrow).
a
a
b b Figure 1: (a) Initial Doppler ultrasound shows minimal peritesticular fluid (arrow head). (b) Enlarged right epididymis with increased vascularity denoting acute epididymitis (white arrow) and testis showing normal vascularity (black arrow).
Figure 3: (a) Partially regained perfusion of the testis (black arrow). (b) Irregular hypoechoic area in the upper pole of testis suggestive of segmental infarction (white arrow). The patient was admitted and treated conservatively. On tenth day of hospital stay, he developed a tender fluctuant swelling in the right testis with associated fever and chills. Repeat Doppler
Oman Medical Journal 2010, Volume 25, Issue 4, October 2010
Segmental Infarction... Parambath et al.
ultrasound revealed an avascular hypoechoic area measuring 3x 1.8 cm in the upper pole of the testis with regained perfusion in the other parts of the testis, (Fig. 3 a, b). Immediate orchidectomy was performed and histopathological examination confirmed segmental infarction of the testis with necrosis.
Discussion
Conclusion This case is reported to illustrate a rare complication of acute epididymitis and to highlight the importance performing follow up Doppler ultrasound, especially when the symptoms persist in spite of treatment.
Acknowledgements Epididymitis is an inflammation limited to epididymis, seen approximately in 1 in 1000 men per year.1 Accurate diagnosis and differentiation from other conditions are possible with Doppler ultrasound. Even though most of the cases respond to antibiotic treatment, progression of infection can sometimes lead to epididymo orchitis or abscess formation. Acute epididymitis causing testicular infarction is extremely rare. Mittemeyer in a series 610 cases of epididymitis reported no cases of testicular ischemia.2 Ischemic process can be segmental or diffuse, depending on the level of vascular occlusion.3,4 Pathogenesis postulated include venous obstruction due to edema, inflammation of spermatic cord (funiculitis), bacterial toxin causing endothelial damage and thrombus formation. Other causes of segmental infarction include vasculitis and hematologic disorders (sickle cell disease and polycythemia).5,6,7 In the present case, the initial Doppler evaluation showed a hypervascular epididymis with normal testicular flow and a diagnosis of acute epididymitis was suggested in correlation with the clinical picture. Even though a hyper vascular epididymis is a definite sign of epididymitis, it can rarely be seen in acute torsion (up to 5%) and in case of spontaneous or manual detorsion.8 Torsion was excluded in this case by demonstration of testicular flow in the initial scan itself. Peculiar clinical course and findings in repeat Doppler also ruled out the possibility of detorsion.
The authors reported no conflict of interest and no funding was received on this work.
References 1. Drotman DP. Epidemiology and treatment of epididymitis. Rev Infect Dis 1984; 4:788. 2. Mittemeyer BT, Lennox KW, Borski AA. Epididymitis: a review of 610 cases. J Urol March 1966; 95(3):390-392. 3. Costa M, Calleja R, Ball RY, Burgess N. Segmental testicular infarction. BJU Int March 1999; 83(4):525. 4. Bird K, Rosenfield AT. Testicular infarction secondary to acute inflammatory disease: demonstration by B-scan ultrasound. Radiology September 1984; 152(3):785-788. 5. Renckien RK, Du Plesis DJ, De Haas LS. Venous infarction of the testis-a cause of non-response to conservative therapy in epididymolorchitis. S Afr Med 1990; 78:337-338. 6. Gofrit ON, Rund D, Shapiro A, Pappo O, Landau EH, Pode D. Segmental testicular infarction due to sickle cell disease. J Urol September 1998; 160(3 Pt 1):835-836. 7. Baer HM, Gerber WL, Kendall AR, Locke JL, Putong PB. Segmental infarct of the testis due to hypersensitivity angiitis. J Urol July 1989; 142(1):125-127. 8. Nussbaum Blask AR, Rushton HG. Sonographic appearance of the epididymis in pediatric testicular torsion. AJR Am J Roentgenol December 2006; 187(6):1627-1635.
Oman Medical Journal 2010, Volume 25, Issue 4, October 2010
From the Department of Emergency Radiology, Hamad Medical Corporation, Doha, Qatar. Received: 18 Jul 2010 Accepted: 14 Aug 2010 Address correspondence and reprint request to: Dr. Arif Nelliyulla Parambath Specialist, Emergency Radiology Hamad Medical Corporation 3050 Doha, Qatar Email: [email protected]
doi:10.5001/omj.2010.95
Introduction
T
esticular ischemia and segmental infarction are rare complications of acute epididymitis. Accurate diagnosis is essential for instituting proper treatment. Doppler ultrasound is an efficient modality for assessing the serial changes in the vascularity of the testis. Lack of symptomatic improvement is a clear justification for perfoming repeat Doppler ultrasound in acute epididymitis.
On the third day after admission, the patient again presented with increased scrotal pain and swelling. A repeat Doppler study showed total ischemia of the testis with slightly increased vascularity, persisting in the epididymis. (Figs. 2 a & b)
a
b
Case Report A 31 year old patient presented to the emergency department with acute scrotal pain, swelling, dysuria and fever. On examination, he had a tender swelling of the right testis with preservation of cremasteric reflex. Laboratory studies were normal except for mild elevation of WBC count. Doppler ultrasound of the scrotum revealed an enlarged epididymis with increased vascularity and minimal peritesticular fluid, consistent with acute epididymitis. The testis showed normal echotexture and vascularity (Figs. 1a, b). The patient was discharged with antibiotic and analgesics.
Figure 2: (a) Absent testicular flow suggestive of testicular ischemia (white arrow). (b) Hypervasular epididymis (black arrow).
a
a
b b Figure 1: (a) Initial Doppler ultrasound shows minimal peritesticular fluid (arrow head). (b) Enlarged right epididymis with increased vascularity denoting acute epididymitis (white arrow) and testis showing normal vascularity (black arrow).
Figure 3: (a) Partially regained perfusion of the testis (black arrow). (b) Irregular hypoechoic area in the upper pole of testis suggestive of segmental infarction (white arrow). The patient was admitted and treated conservatively. On tenth day of hospital stay, he developed a tender fluctuant swelling in the right testis with associated fever and chills. Repeat Doppler
Oman Medical Journal 2010, Volume 25, Issue 4, October 2010
Segmental Infarction... Parambath et al.
ultrasound revealed an avascular hypoechoic area measuring 3x 1.8 cm in the upper pole of the testis with regained perfusion in the other parts of the testis, (Fig. 3 a, b). Immediate orchidectomy was performed and histopathological examination confirmed segmental infarction of the testis with necrosis.
Discussion
Conclusion This case is reported to illustrate a rare complication of acute epididymitis and to highlight the importance performing follow up Doppler ultrasound, especially when the symptoms persist in spite of treatment.
Acknowledgements Epididymitis is an inflammation limited to epididymis, seen approximately in 1 in 1000 men per year.1 Accurate diagnosis and differentiation from other conditions are possible with Doppler ultrasound. Even though most of the cases respond to antibiotic treatment, progression of infection can sometimes lead to epididymo orchitis or abscess formation. Acute epididymitis causing testicular infarction is extremely rare. Mittemeyer in a series 610 cases of epididymitis reported no cases of testicular ischemia.2 Ischemic process can be segmental or diffuse, depending on the level of vascular occlusion.3,4 Pathogenesis postulated include venous obstruction due to edema, inflammation of spermatic cord (funiculitis), bacterial toxin causing endothelial damage and thrombus formation. Other causes of segmental infarction include vasculitis and hematologic disorders (sickle cell disease and polycythemia).5,6,7 In the present case, the initial Doppler evaluation showed a hypervascular epididymis with normal testicular flow and a diagnosis of acute epididymitis was suggested in correlation with the clinical picture. Even though a hyper vascular epididymis is a definite sign of epididymitis, it can rarely be seen in acute torsion (up to 5%) and in case of spontaneous or manual detorsion.8 Torsion was excluded in this case by demonstration of testicular flow in the initial scan itself. Peculiar clinical course and findings in repeat Doppler also ruled out the possibility of detorsion.
The authors reported no conflict of interest and no funding was received on this work.
References 1. Drotman DP. Epidemiology and treatment of epididymitis. Rev Infect Dis 1984; 4:788. 2. Mittemeyer BT, Lennox KW, Borski AA. Epididymitis: a review of 610 cases. J Urol March 1966; 95(3):390-392. 3. Costa M, Calleja R, Ball RY, Burgess N. Segmental testicular infarction. BJU Int March 1999; 83(4):525. 4. Bird K, Rosenfield AT. Testicular infarction secondary to acute inflammatory disease: demonstration by B-scan ultrasound. Radiology September 1984; 152(3):785-788. 5. Renckien RK, Du Plesis DJ, De Haas LS. Venous infarction of the testis-a cause of non-response to conservative therapy in epididymolorchitis. S Afr Med 1990; 78:337-338. 6. Gofrit ON, Rund D, Shapiro A, Pappo O, Landau EH, Pode D. Segmental testicular infarction due to sickle cell disease. J Urol September 1998; 160(3 Pt 1):835-836. 7. Baer HM, Gerber WL, Kendall AR, Locke JL, Putong PB. Segmental infarct of the testis due to hypersensitivity angiitis. J Urol July 1989; 142(1):125-127. 8. Nussbaum Blask AR, Rushton HG. Sonographic appearance of the epididymis in pediatric testicular torsion. AJR Am J Roentgenol December 2006; 187(6):1627-1635.
Oman Medical Journal 2010, Volume 25, Issue 4, October 2010
