A 30-year-old male presented with a 1-day history of left scrotal pain and a tender left testicle and epididymis on physical exam. Scrotal ultrasound showed an avascular, heterogeneous, hypoechoic lesion in the superior left testis suggestive of infarction or neoplasm. The patient was managed conservatively; however, his pain continued and follow-up ultrasound 6 days later showed interval increase in the size of the mass. Left radical orchiectomy was done and pathology result showed segmental infarction of the left testis.
Segmental testicular infarction is a rare condition that presents with acute scrotal pain and is often clinically indistinguishable from other etiologies of scrotal pain. The diagnosis often relies on imaging studies, with testicular neoplasm being the most important differential diagnosis. If the condition is diagnosed or suspected on imaging studies, patients can be managed conservatively and often improve. However, orchiectomy to obtain pathologic diagnosis may be required in a significant number of patients when the diagnosis is uncertain. We present a patient with segmental scrotal infarction who did not improve with conservative management and subsequently underwent orchiectomy.
A 30-year-old male with history of motor vehicle accident leading to urinary frequency and occasional incontinence 1.5 years ago presented with 1-day history of left groin pain, which was gradually improving. On physical examination, he had a tender left testicle and epididymis with no significant swelling or systemic signs of inflammation. High frequency ultrasound including color-Doppler showed an avascular, heterogeneous, hypoechoic lesion in the superior left testis suggestive of infarction or neoplasm. Bilateral microlithiasis was also noted (Figure
Color-Doppler ultrasound image of the left testis shows an avascular echogenic lesion with hypoechoic center.
Follow-up color-Doppler ultrasound image shows interval enlargement of the testicular lesion.
Section shows a well-defined area of infarction surrounded by an area of fibrosis and tubular atrophy. Outlines of the tubules are remaining but loss of nuclear details and hemorrhagic with hemorrhagic interstitium. There is no significant inflammation or evidence of neoplasm.
The unique anatomical location of testis, lying within an external body sac while hanging from its vascular pedicle, makes it hypermobile and prone to vascular accidents compared to other body organs. Congenital abnormalities like “bell-clapper” deformity with abnormal attachment of the testis to its muscular and facial layers increase the chance of testicular ischemic events [
Although the majority of cases with STI are idiopathic, conditions like vasculitis, sickle cell disease, polycythemia, epididymitis, intimal fibroplasia of spermatic artery, hypersensitivity angiitis, trauma, or prior testicular torsion can predispose to this condition. It can happen in any age range; however, it is a rare condition in the pediatric population [
Ultrasound is usually the first step to diagnosis; however, seminomatous and nonseminomatous testicular masses can easily mimic the STI appearance on ultrasound.
On gray-scale imaging, a wedge-shaped hypoechoic lesion with the apex pointing to the rete testis can be suggestive of arterial infarction. Arterial infarctions are more often seen in the upper poles of the testes [
Magnetic resonance imaging (MRI) has also occasionally been used to aid in diagnosis. MRI can better show the lesion borders and the T2-weighted images can show low intensity signal (but can be variable) in patients with infarction. The surrounding enhanced rim can also be seen in MRI after administration of contrast [
Despite the available imaging modalities, the diagnosis of segmental testicular infarction remains challenging. The radiologic-pathologic correlation in most case series remains suboptimal and definitive diagnosis in many patients is obtained after orchiectomy [
Acute onset of testicular pain with normal levels of tumor and inflammatory markers and presence of a wedge-shaped, avascular hypoechoic heterogenous lesion on color-Doppler ultrasound can be highly suggestive of segmental testicular infarction. The clinical and radiographic aspects of a case should be considered altogether to avoid unnecessary orchiectomy.
The authors declare that there is no conflict of interests regarding the publication of this paper.