Segmental testicular infarction is a rare cause of acute scrotum. Its aetiology is not well defined and it can be clinically confused with a testicular tumour. Because the differential diagnosis between segmental testicular infarction and testicular tumour can be difficult, most authors in the past recommended surgery. Imaging plays an important role in the preoperative diagnosis, with a colour Doppler ultrasonography as the investigation of choice although magnetic resonance imaging (MRI) can be useful in doubtful cases. The objective of this retrospective study was to describe the radiologic findings and the outcome of conservative management in a single-centre experience of 19 cases of segmental testicular infarction.
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Case report
The database of men presenting with acute scrotum between October 1997 and June 2006 was reviewed and electronic files of all the patients diagnosed with segmental testicular infarction were selected for detailed evaluation. In 19 patients presenting with acute testicular pain the diagnosis of segmental testicular infarction was made on colour Doppler ultrasonography or on histologic examination after surgery. Magnetic resonance imaging (MRI) was performed in six patients to confirm the
EU-ACME question
Please visit www.eu-acme.org/europeanurology to answer the below EU-ACME question on-line (the EU-ACME credits will be attributed automatically). The answer will be given in Case Study of the Month: Part 2, which will be published in next month's issue of European Urology. Question:
Which of the following statements is true with regards to segmental testicular infarction?
A.
It appears as focal avascular area on colour Doppler ultrasound with normal remaining parenchyma.
2023, Magnetic Resonance Imaging of The Pelvis: A Practical Approach
In the acute setting, the main role of scrotal imaging is to provide timely and accurate diagnostic information of scrotal pathologies to set forth opportune treatment. In the nonacute/chronic setting, the role of scrotal imaging spans a wider range that includes mass evaluation, for which the clinical presentation, and imaging appearance guides whether to pursue testis-sparing or life-altering treatments such as radical orchiectomy. To date, ultrasound remains as the primary modality for the evaluation of scrotal pathology. However, the inherent constraints of ultrasound, such as operator experience, narrow field of view, and limited soft tissue characterization, preclude optimal characterization of scrotal lesions.1 The utility of MRI in scrotal diseases has been shown in many studies. In a study by Parenti et al., MRI was necessary in 5.74% of patients to detect scrotal disease following ultrasound and excluded focal lesions in almost 50% of cases.2 Additionally, MR imaging has been shown to increase sensitivity and specificity for the detection of benign intratesticular lesions with a reported accuracy of 87.5% and NPV of 100%.3 The main goal of this chapter is to expose the reader to a wide variety of scrotal pathologies commonly and uncommonly encountered in practice and discuss the evolving evidence-based role of MRI in the diagnostic and preoperative workup of scrotal lesions.
Segmental testicular infarction is a rare clinical condition most often seen as acute unilateral scrotal pain. Segmental testicular infarction should be suspected in patients with scrotal pain; when an ultrasound shows hypoechoic or mixed echogenic lesions within the testicular parenchyma; contrast-enhanced ultrasound shows a little or no contrast filling, along with negative multiple tumor markers. This report presents a 60-year-old male who presented with sudden onset of left testicular pain with no apparent cause. Emergency Doppler ultrasound, contrast-enhanced ultrasound, and laboratory tests showed findings characteristic of Segmental testicular infarction. The patient the final diagnosis was based on a combination of clinical findings (regression or cessation of symptoms, no tumor marker abnormalities, no palpable testicular mass) and ultrasound evidence of improvement (size reduction or shape change from oval to wedge) during a follow-up period of at least 3 months.
Segmental testicular infarct is a rare clinical entity and can be a diagnostic challenge. Although cases are often idiopathic, underlying etiologies can include testicular torsion, epididymo-orchitis, trauma, vasculitis, and hypercoagulable states. Once suspected, an underlying testicular neoplasm should be excluded. We present a case of a 43-year-old male who developed acute onset left sided scrotal pain. A diagnostic scrotal ultrasound showed a focal, heterogeneous region in left testicle with absent focal Doppler signal, concerning for a segmental testicular infarction. There was no history of trauma, urinary symptoms, sexually transmitted diseases, or constitutional symptoms. Work up for associated underlying etiologies was negative. A computed tomography angiogram scan of the abdomen and pelvis revealed an incidental left testicular artery aneurysm. The patient's consulting multidisciplinary care teams included urology and vascular surgery. Urology deemed surgical intervention inappropriate for the segmental testicular infarct, and vascular surgery elected not to intervene on the testicular artery aneurysm due to risk of completing testicular infarct and damaging blood supply to the testis. The patient was discharged after achieving adequate pain control, and completion of inpatient work up. No underlying malignancy was diagnosed on follow up, and pain symptoms resolved. To the authors’ knowledge, no literature exists describing the concurrent incidence of a segmental testicular infarct and an ipsilateral testicular artery aneurysm. In this report, we aim to further describe both diagnoses, and explore the association between the 2 entities.
Definite diagnosis can be made by histological examination of the orchiectomy specimen; therefore, some experts recommend surgery. [6] With the increase of clinical and radiological awareness, conservative management is considered more frequently. [1] A 43-year-old male with a previous medical history of anxiety disorder and liver steatosis presented to the emergency department with left testicular pain that had started 24 hours beforehand and had intensified prior to consultation.
A 43-year-old male presented to the emergency department with acute left testicular pain. Physical exam showed a tender left testicle and epididymis with mild swelling. Doppler and contrast enhanced ultrasound revealed a heterogeneous, avascular lesion with hyper vascularized surrounding. Follow-up contrast enhanced ultrasound performed a few days later showed persistence of the sparsely vascularized lesion with more hypoechoic echo structure.
Despite the tumor markers being negative, a necrotic tumor could not be ruled out and a left orchiectomy was performed. Pathology report described an extensive segmental testicular infarction with no evidence of malignant tissue.
We present the ultrasound and pathology findings, differential diagnostic pearls and clinical perspective of segmental testicular infarction.
There is limited evidence in the literature in regard to the management of segmental testicular infarction secondary to epididymo-orchitis. A retrospective cohort study was undertaken at a single centre in Belgium from 1997 to 2006 which reviewed patients with segmental testicular infarction.2 Of the 19 cases identified, 16 were managed conservatively without an operation and all reported a resolution in symptoms.2
Segmental infarction of the testicle secondary to epididymo-orchitis is a rare condition which can be difficult to diagnose and can lead to loss of the testis. We report a case of a 72-year-old man who presented with two weeks of worsening pain of his left testis despite oral antibiotic treatment for epididymo-orchitis. A testicular ultrasound initially revealed a suspected intra-testicular abscess. Despite intravenous antibiotics, his symptoms worsened. A repeat ultrasound demonstrated an increase in size of the lesion and a decision was made to take him to theatre. Intra-operative findings instead revealed a segmental area of testicular infarction requiring debridement.
