SRU RESIDENT TEACHING CASE
Identify Before Orchiectomy Segmental Testicular Infarct Joel P. Thompson, MD, MPH, Shweta Bhatt, MBBS, and Deborah Rubens, MD CLINICAL HISTORY A 26-year-old male patient with past medical history of anxiety and migraines presents with sudden onset bilateral scrotal pain. The pain started suddenly in the right testis the night before, then shifted to the left testis the morning of presentation. There was no history of trauma, abnormal genitourinary development, sexually transmitted infection, or urinary tract infections. The patient reported normal urination. The physical examination result is significant for exquisite bilateral testicular tenderness, with pain radiating into the groin and up the back. No palpable masses or spermatic cord tenderness. At presentation, the patient was afebrile with leukocytosis of 16.1 thousand/KL. The remaining initial laboratory examination findings were unremarkable, including a clean urinalysis result. Scrotal ultrasound (US) was ordered (Fig. 1).
DIAGNOSIS The diagnosis is segmental testicular infarctions (STIs).
DISCUSSION Segmental testicular infarction is a rare cause of acute scrotal pain and occurs mainly in males aged 20 to 40 years. Various medical conditions predispose to STI include recent epididymo-orchitis, trauma, vasculitis, and hypercoagulable states (sickle cell disease and polycythemia).1,2 Segmental testicular infarction has also been reported after surgical procedures, such as inguinal hernia repair, vasectomy, or vericocelectomy.3 However, most are idiopathic. In 1 retrospective review, STI was present on 0.3% of US scrotal examinations.4 Most STI lesions occur in the upper pole of the testis,2,4,5 likely due to differences in vascular supply between the upper and lower poles of the testis. The deferens artery anastomoses with the posterior epididymal artery (branch of the testicular artery) and thus may provide collateral flow to
Received for publication October 14, 2014; accepted November 25, 2014. Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY. The authors declare no conflict of interest. Reprints; Joel P. Thompson MD, MPH, Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642 (e-mail: [email protected]). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
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the lower pole of the testis. The upper pole receives blood solely from the anterior epididymal artery and thus is at increased risk for vascular insult.2 There is no consistent predilection for side among published case series. Identification of STI is important to avoid unnecessary orchiectomy. The diagnosis of STI is based on characteristic imaging findings (detailed below) and the absence of serum tumor markers. Follow-up imaging is advised; this patient received follow-up US examinations 2 weeks, 1 month, and 6 weeks after presentation. Magnetic resonance imaging may also be obtained for further characterization. Orchiectomy for presumed tumor may be avoided if symptoms resolve and the lesion shrinks or remains stable in size.5 Ultrasound is the study of choice in the evaluation of acute scrotal pain.6 The presence of an isoechoic or hypoechoic lesion with absent internal flow on color Doppler should prompt inclusion of STI in the differential diagnosis.1 Acutely, STI appears as a wedge-shaped or oval lesion measuring about 1 to 2 cm, with ill-defined margins and predominantly isoechoic to adjacent parenchyma.2,4,5 Internal color Doppler signal is either absent (over 80% of cases) or significantly decreased. Increased perilesional color Doppler flow is often present,4 which is thought to be related to perilesional edema.5 A focus of internal increased echogenicity may represent internal hemorrhage.3 The subacute appearance of STI (days 2Y17) includes progressively decreased internal echogenicity (hypoechoic to adjacent testicular parenchyma) and more discrete margins.5 Increased perilesional flow on color Doppler imaging remains. If the infarct involves adjacent parenchymal regions, a bridging centripetal artery may be identified. During later follow-up, the peripheral flow on color Doppler imaging resolves, and the lesion either diminishes or is stable in size. If the lesion decreases in size, retraction of the overlying tunica albuginea may be identified. In 1 study, wedge-shaped lesions were associated with spermatic cord torsion.4 The vertex of the wedge-shaped infarct typically points toward the mediastinum testis.2 In this same study, oval/round lesions were associated with epididymo-orchitis, raising speculation that round lesions represent venous drainage compromise and wedge-shaped lesions arterial compromise.4 Although there is increased perilesional color Doppler signal surrounding the infarct, there is no significant rim enhancement on contrast-enhanced US in the acute setting.5 Between 2 and 17 days, 86% of follow-up contrast-enhanced US studies demonstrated perilesional rim enhancement; this disappeared by 1 month.5 The presence of both increased color Doppler signal and enhancement in the subacute period may be due to both Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Identify Before Orchiectomy
FIGURE 1. A 26-year-old male with sudden onset bilateral testicular pain. A, Midline transverse US image of the scrotum demonstrates heterogeneous lesions within both testis (yellow arrows), predominantly hypoechoic to the adjacent parenchyma on the right and hyperechoic on the left. B, Midline transverse color Doppler image of the scrotum demonstrates increased vascularity within both testis but no internal vascularity within the lesions. C, Color Doppler image of the right testicular lesion demonstrates a bridging centripetal artery, indicating that the lesion involves multiple segments. The centripetal artery has a normal low resistance arterial spectral waveform. Differential diagnoses include STIs, hematomas, or tumors with low vascularity. Figure 1 B and C can be viewed in color online at www.ultrasound-quarterly.com.
FIGURE 2. Follow-up US 2 days later for continued testicular pain. Long axis image of the right testis demonstrates interval development of a new heterogeneous hypoechoic lesion (white arrow), without internal vascularity. The original right testicular lesion was unchanged in size and appearance (yellow arrow). Figure 2 can be viewed in color online at www.ultrasound-quarterly.com.
perilesional inflammatory cells and early neovascular formation in the setting of ischemia.5 Magnetic resonance imaging is useful for further characterizing lesions identified on US. Lesions are usually low or intermediate T1 signal, variable T2 signal, and demonstrate no central enhancement on postcontrast images. High T1 signal centrally within the lesion indicates the presence of hemorrhage.1 The most common finding is a markedly enhancing rim (occurring in 990% of cases in 1 series).1,2 As on US, lesions may be oval/round or wedge-shaped with apex directed toward the rete testis. Follow-up imaging may demonstrate volume loss and/or fibrosis in the area of infarct, identified as retraction of the overlying tunica albuginea.1 The differential diagnosis of STI includes small hypovascular tumors, abscess, and hematoma. On US, abscesses are usually anechoic or hypoechoic to testicular parenchyma, may show increased through transmission, and have low-level internal echoes.3 Perilesional hyperemia is often more pronounced in STI than in abscess.5 Small hypovascular tumors are excluded based on serum tumor marker levels and follow-up imaging. Hematomas may be excluded based on patient history of trauma.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ultrasound-quarterly.com
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Ultrasound Quarterly
Thompson et al
& Volume 31, Number 3, September 2015
FIGURE 3. Magnetic resonance T1 fat-saturated postcontrast coronal image (A) and LAVA subtraction image (B) day 3 after presentation demonstrate the bilateral testicular lesions with a thin rim of surrounding enhancement (white arrows). The lesions were intermediate T1 signal and low T2 signal (not shown). Small hydroceles are partially visualized.
This patient was admitted to the hospital for pain control after the first US was obtained. He was treated empirically with doxycycline and ciprofloxacin for potential epididymoorchitis, given his leukocytosis and testicular/epididymal hyperemia on US. The leukocytosis resolved by hospital day 2. Due to increased pain on hospital day 2, a second scrotal US was obtained (Fig. 2). Pertinent laboratory examination findings at that time included negative tumor markers (A-HCG, G1 mIU/mL; lactate dehydrogenase, 251 U/L) and low testosterone level (118 ng/dL; reference range, 249-836 ng/dL). The hematology service was consulted for potential ischemic/thromboembolic event, but a hypercoagulable workup was negative. Rheumatology was consulted for possible vasculitic etiology, but this was thought to be unlikely due to negative workup (negative ANA and ANCA) and lack of systemic findings; in addition, single organ vasculitis was not
thought to be associated with elevated inflammatory markers, such as the patient’s slightly elevated C-reactive protein level (110 mg/L) and erythrocyte sedimentation rate (43 mm/h). At this time, the magnetic resonance imaging of the testis was obtained, which was consistent with STI (Fig. 3). No definite underlying etiology was identified. The patient was discharged and followed on an outpatient basis. Follow-up US imaging was performed (Fig. 4). The patient’s pain was controlled using nonsteroidal antiinflammatory drugs, oral pain medical treatment, and spermatic cord injections with 0.5% marcaine. This patient was able to avoid orchiectomy by correct identification of STI on the initial US, a diagnosis that was confirmed by follow-up imaging and lack of serum tumor markers, highlighting the importance of identifying this rare cause of acute scrotal pain.
FIGURE 4. Follow-up imaging. A, Transverse midline scrotal US image 2 weeks after presentation demonstrates evolution of the testicular infarcts, now appearing hypoechoic and slightly decreased in size. B, Long axis US image of the right testis 1 month after presentation demonstrates continued evolution of the infarct, with overall decreased size compared with prior US examinations (longest dimension 1.6 cm compared with 2.7 cm on original US in Fig. 1). Figure 4B can be viewed in color online at www.ultrasound-quarterly.com.
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www.ultrasound-quarterly.com
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly
& Volume 31, Number 3, September 2015 REFERENCES
1. Cassidy FH, et al. MR imaging of scrotal tumors and pseudotumors. Radiographics. 2010;30(3):665Y683. 2. Fernandez-Perez GC, et al. Radiologic findings of segmental testicular infarction. AJR Am J Roentgenol. 2005;184(5): 1587Y1593. 3. Bhatt S, et al. Imaging of non-neoplastic intratesticular masses. Diagn Interv Radiol. 2011;17(1):52Y63.
Identify Before Orchiectomy 4. Bilagi P, et al. Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Eur Radiol. 2007;17(11):2810Y2818. 5. Bertolotto M, et al. Acute segmental testicular infarction at contrast-enhanced ultrasound: early features and changes during follow-up. AJR Am J Roentgenol. 2011;196(4):834Y841. 6. Remer EM, et al. ACR Appropriateness Criteria (R) acute onset of scrotal painVwithout trauma, without antecedent mass. Ultrasound Q. 2012;28(1):47Y51.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ultrasound-quarterly.com
201
Identify Before Orchiectomy Segmental Testicular Infarct Joel P. Thompson, MD, MPH, Shweta Bhatt, MBBS, and Deborah Rubens, MD CLINICAL HISTORY A 26-year-old male patient with past medical history of anxiety and migraines presents with sudden onset bilateral scrotal pain. The pain started suddenly in the right testis the night before, then shifted to the left testis the morning of presentation. There was no history of trauma, abnormal genitourinary development, sexually transmitted infection, or urinary tract infections. The patient reported normal urination. The physical examination result is significant for exquisite bilateral testicular tenderness, with pain radiating into the groin and up the back. No palpable masses or spermatic cord tenderness. At presentation, the patient was afebrile with leukocytosis of 16.1 thousand/KL. The remaining initial laboratory examination findings were unremarkable, including a clean urinalysis result. Scrotal ultrasound (US) was ordered (Fig. 1).
DIAGNOSIS The diagnosis is segmental testicular infarctions (STIs).
DISCUSSION Segmental testicular infarction is a rare cause of acute scrotal pain and occurs mainly in males aged 20 to 40 years. Various medical conditions predispose to STI include recent epididymo-orchitis, trauma, vasculitis, and hypercoagulable states (sickle cell disease and polycythemia).1,2 Segmental testicular infarction has also been reported after surgical procedures, such as inguinal hernia repair, vasectomy, or vericocelectomy.3 However, most are idiopathic. In 1 retrospective review, STI was present on 0.3% of US scrotal examinations.4 Most STI lesions occur in the upper pole of the testis,2,4,5 likely due to differences in vascular supply between the upper and lower poles of the testis. The deferens artery anastomoses with the posterior epididymal artery (branch of the testicular artery) and thus may provide collateral flow to
Received for publication October 14, 2014; accepted November 25, 2014. Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY. The authors declare no conflict of interest. Reprints; Joel P. Thompson MD, MPH, Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642 (e-mail: [email protected]). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
198
www.ultrasound-quarterly.com
the lower pole of the testis. The upper pole receives blood solely from the anterior epididymal artery and thus is at increased risk for vascular insult.2 There is no consistent predilection for side among published case series. Identification of STI is important to avoid unnecessary orchiectomy. The diagnosis of STI is based on characteristic imaging findings (detailed below) and the absence of serum tumor markers. Follow-up imaging is advised; this patient received follow-up US examinations 2 weeks, 1 month, and 6 weeks after presentation. Magnetic resonance imaging may also be obtained for further characterization. Orchiectomy for presumed tumor may be avoided if symptoms resolve and the lesion shrinks or remains stable in size.5 Ultrasound is the study of choice in the evaluation of acute scrotal pain.6 The presence of an isoechoic or hypoechoic lesion with absent internal flow on color Doppler should prompt inclusion of STI in the differential diagnosis.1 Acutely, STI appears as a wedge-shaped or oval lesion measuring about 1 to 2 cm, with ill-defined margins and predominantly isoechoic to adjacent parenchyma.2,4,5 Internal color Doppler signal is either absent (over 80% of cases) or significantly decreased. Increased perilesional color Doppler flow is often present,4 which is thought to be related to perilesional edema.5 A focus of internal increased echogenicity may represent internal hemorrhage.3 The subacute appearance of STI (days 2Y17) includes progressively decreased internal echogenicity (hypoechoic to adjacent testicular parenchyma) and more discrete margins.5 Increased perilesional flow on color Doppler imaging remains. If the infarct involves adjacent parenchymal regions, a bridging centripetal artery may be identified. During later follow-up, the peripheral flow on color Doppler imaging resolves, and the lesion either diminishes or is stable in size. If the lesion decreases in size, retraction of the overlying tunica albuginea may be identified. In 1 study, wedge-shaped lesions were associated with spermatic cord torsion.4 The vertex of the wedge-shaped infarct typically points toward the mediastinum testis.2 In this same study, oval/round lesions were associated with epididymo-orchitis, raising speculation that round lesions represent venous drainage compromise and wedge-shaped lesions arterial compromise.4 Although there is increased perilesional color Doppler signal surrounding the infarct, there is no significant rim enhancement on contrast-enhanced US in the acute setting.5 Between 2 and 17 days, 86% of follow-up contrast-enhanced US studies demonstrated perilesional rim enhancement; this disappeared by 1 month.5 The presence of both increased color Doppler signal and enhancement in the subacute period may be due to both Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly
& Volume 31, Number 3, September 2015
Identify Before Orchiectomy
FIGURE 1. A 26-year-old male with sudden onset bilateral testicular pain. A, Midline transverse US image of the scrotum demonstrates heterogeneous lesions within both testis (yellow arrows), predominantly hypoechoic to the adjacent parenchyma on the right and hyperechoic on the left. B, Midline transverse color Doppler image of the scrotum demonstrates increased vascularity within both testis but no internal vascularity within the lesions. C, Color Doppler image of the right testicular lesion demonstrates a bridging centripetal artery, indicating that the lesion involves multiple segments. The centripetal artery has a normal low resistance arterial spectral waveform. Differential diagnoses include STIs, hematomas, or tumors with low vascularity. Figure 1 B and C can be viewed in color online at www.ultrasound-quarterly.com.
FIGURE 2. Follow-up US 2 days later for continued testicular pain. Long axis image of the right testis demonstrates interval development of a new heterogeneous hypoechoic lesion (white arrow), without internal vascularity. The original right testicular lesion was unchanged in size and appearance (yellow arrow). Figure 2 can be viewed in color online at www.ultrasound-quarterly.com.
perilesional inflammatory cells and early neovascular formation in the setting of ischemia.5 Magnetic resonance imaging is useful for further characterizing lesions identified on US. Lesions are usually low or intermediate T1 signal, variable T2 signal, and demonstrate no central enhancement on postcontrast images. High T1 signal centrally within the lesion indicates the presence of hemorrhage.1 The most common finding is a markedly enhancing rim (occurring in 990% of cases in 1 series).1,2 As on US, lesions may be oval/round or wedge-shaped with apex directed toward the rete testis. Follow-up imaging may demonstrate volume loss and/or fibrosis in the area of infarct, identified as retraction of the overlying tunica albuginea.1 The differential diagnosis of STI includes small hypovascular tumors, abscess, and hematoma. On US, abscesses are usually anechoic or hypoechoic to testicular parenchyma, may show increased through transmission, and have low-level internal echoes.3 Perilesional hyperemia is often more pronounced in STI than in abscess.5 Small hypovascular tumors are excluded based on serum tumor marker levels and follow-up imaging. Hematomas may be excluded based on patient history of trauma.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ultrasound-quarterly.com
199
Ultrasound Quarterly
Thompson et al
& Volume 31, Number 3, September 2015
FIGURE 3. Magnetic resonance T1 fat-saturated postcontrast coronal image (A) and LAVA subtraction image (B) day 3 after presentation demonstrate the bilateral testicular lesions with a thin rim of surrounding enhancement (white arrows). The lesions were intermediate T1 signal and low T2 signal (not shown). Small hydroceles are partially visualized.
This patient was admitted to the hospital for pain control after the first US was obtained. He was treated empirically with doxycycline and ciprofloxacin for potential epididymoorchitis, given his leukocytosis and testicular/epididymal hyperemia on US. The leukocytosis resolved by hospital day 2. Due to increased pain on hospital day 2, a second scrotal US was obtained (Fig. 2). Pertinent laboratory examination findings at that time included negative tumor markers (A-HCG, G1 mIU/mL; lactate dehydrogenase, 251 U/L) and low testosterone level (118 ng/dL; reference range, 249-836 ng/dL). The hematology service was consulted for potential ischemic/thromboembolic event, but a hypercoagulable workup was negative. Rheumatology was consulted for possible vasculitic etiology, but this was thought to be unlikely due to negative workup (negative ANA and ANCA) and lack of systemic findings; in addition, single organ vasculitis was not
thought to be associated with elevated inflammatory markers, such as the patient’s slightly elevated C-reactive protein level (110 mg/L) and erythrocyte sedimentation rate (43 mm/h). At this time, the magnetic resonance imaging of the testis was obtained, which was consistent with STI (Fig. 3). No definite underlying etiology was identified. The patient was discharged and followed on an outpatient basis. Follow-up US imaging was performed (Fig. 4). The patient’s pain was controlled using nonsteroidal antiinflammatory drugs, oral pain medical treatment, and spermatic cord injections with 0.5% marcaine. This patient was able to avoid orchiectomy by correct identification of STI on the initial US, a diagnosis that was confirmed by follow-up imaging and lack of serum tumor markers, highlighting the importance of identifying this rare cause of acute scrotal pain.
FIGURE 4. Follow-up imaging. A, Transverse midline scrotal US image 2 weeks after presentation demonstrates evolution of the testicular infarcts, now appearing hypoechoic and slightly decreased in size. B, Long axis US image of the right testis 1 month after presentation demonstrates continued evolution of the infarct, with overall decreased size compared with prior US examinations (longest dimension 1.6 cm compared with 2.7 cm on original US in Fig. 1). Figure 4B can be viewed in color online at www.ultrasound-quarterly.com.
200
www.ultrasound-quarterly.com
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Ultrasound Quarterly
& Volume 31, Number 3, September 2015 REFERENCES
1. Cassidy FH, et al. MR imaging of scrotal tumors and pseudotumors. Radiographics. 2010;30(3):665Y683. 2. Fernandez-Perez GC, et al. Radiologic findings of segmental testicular infarction. AJR Am J Roentgenol. 2005;184(5): 1587Y1593. 3. Bhatt S, et al. Imaging of non-neoplastic intratesticular masses. Diagn Interv Radiol. 2011;17(1):52Y63.
Identify Before Orchiectomy 4. Bilagi P, et al. Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Eur Radiol. 2007;17(11):2810Y2818. 5. Bertolotto M, et al. Acute segmental testicular infarction at contrast-enhanced ultrasound: early features and changes during follow-up. AJR Am J Roentgenol. 2011;196(4):834Y841. 6. Remer EM, et al. ACR Appropriateness Criteria (R) acute onset of scrotal painVwithout trauma, without antecedent mass. Ultrasound Q. 2012;28(1):47Y51.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ultrasound-quarterly.com
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