Challenges in the diagnosis of testicular infarction in the presence of prolonged epididymitis: Three cases report and literature review

Article type: Research Article

Authors: Wang, Xisheng^{a; 1} | Zhang, Zejian^{a; 1; *} | Fang, Lie kui^{b; 2} | Chen, Dong^a | Peng, Naixiong^a | Thakker, Parth Udayan^c | Schwartz, Marshall Zane^c | Zhang, Yuanyuan^{c; 2}

Affiliations: [a] Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China | [b] Urinary Surgery Department of the Second Affiliated Hospital of Southern University Of Science And Technology, Shenzhen Third People’s Hospital, Shenzhen, Guangdong Province, China | [c] Department of Urology and Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA

Correspondence: [*] Corresponding author: Zejian Zhang, Department of Urology, Shenzhen Longhua District Central Hospital, The Affiliated Central Hospital of Shenzhen Longhua District, Guangdong Medical University, Shenzhen, Guangdong Province, China. E-mail: [email protected].

Note: [1] Both authors contributed equally to this work.

Note: [2] Co-corresponding authors: Liekui Fang, E-mail: [email protected]; Yuanyuan Zhang, [email protected]

Abstract: INTRODUCTION:Testicular infarction is a rare complication of prolonged epididymitis and may be misdiagnosed as testicular torsion. In this study, we present three cases of testicular infarction and discuss their clinical characteristics, imaging features and clinical management. PATIENTS AND METHODS:Three adult males with prolonged epididymitis presented with chronic unilateral testicular pain, tenderness, and palpable swelling, including left varicocele in one case and hydrocele in the other two cases. Patient’s symptoms were not relieved after antibiotic therapy. We analyzed the diagnosis, management, and outcome of these three cases of testicular infarction resulting from prolonged epididymitis. This includes the clinical characteristics, features of color doppler ultrasound imaging for diagnosis, and treatment strategy for testicular infarction from prolonged epididymitis. RESULTS:Complete blood count (CBC) indicated a small leukocytosis (10.6±0.4×109/L; normal arrange 3.5–9.5 WBC×109/L). Color doppler images demonstrated appropriate blood flow to areas of interest at patient’s initial visit. At follow up visit several months later, the increased blood flow was detected at the edges of the involved testes with no blood flow to the center. The sizes of the involved testis (27±4 ml) was significantly larger compared to the non affected side (17±2 ml) (p < 0.05). Unilateral simple orchiectomy was performed on the involved testis in all three cases. Grossly, abscess cavities with caseous necrosis were found at the center of the testicle and epididymis in two patients. Histopathologic examination showed chronic inflammation with lymphocytic and macrophage infiltration of the involved testicle in two cases. The third case stained positive for acid fast bacteria. Left varicocele disappeared postoperatively in one patient. No pain, wound infection or other discomfort were noted 12 months after surgery. COMMENTS:This series revealed that testicular infarction may result from inappropriately treated prolonged epididymitis. Epididymal tuberculosis should be considered in cases with epididymitis not responding to broad spectrum antibiotics. Testicular infarction induced by prolonged epididymitis is easily missed due to a lack of symptom changes. Color doppler images are helpful in the diagnosis. This usually presents as a decrease in blood flow at the center of the testis with the increased flow at the periphery differentiating this from testicular torsion.

Keywords: Epididymitis, infarction, testicular, orchiectomy, tuberculosis

DOI: 10.3233/XST-200671

Journal: Journal of X-Ray Science and Technology, vol. 28, no. 4, pp. 809-819, 2020