Global Testicular Infarction in the Presence of Epididymitis

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1 CASE SERIES Global Testicular Infarction in the Presence of Epididymitis Clinical Features, Appearances on Grayscale, Color Doppler, and Contrast-Enhanced Sonography, and Histologic Correlation Gibran Yusuf, MBBS, Maria E. Sellars, MBBS, FRCR, Gordon G. Kooiman, MBBS, FRCS, Salvador Diaz-Cano, MD, PhD, FRCPath, Paul S. Sidhu, BSc, MRCP, FRCR Epididymitis is common, presenting indolently with unilateral scrotal pain and swelling. Diagnosis is based on clinical assessment and resolves with antibiotic therapy. Recognized complications are abscess formation and segmental infarction. Global testicular infarction is rare. Diagnosis is important and requires surgical management. On grayscale sonography, global infarction may be difficult to establish. The addition of color Doppler imaging is useful but is observer experience dependent with limitations in the presence of low flow. Contrast-enhanced sonography is useful for unequivocally establishing the diagnosis. We report global testicular infarction in 2 patients with epididymitis clearly depicted on contrast-enhanced sonography, allowing immediate surgical management. Key Words Doppler sonography; epididymitis; infarction; microbubble contrast; testis Received May 15, 2012, from the Departments of Radiology (G.Y., M.E.S., P.S.S.), Urology (G.G.K.), and Pathology (S.D.-C.), King s College London, King s College Hospital, London, England. Revision requested May 30, Revised manuscript accepted for publication June 13, Address correspondence to Paul S. Sidhu, BSc, MRCP, FRCR, Department of Radiology, King s College London, King s College Hospital, Denmark Hill, London SE5 9RS, England. paulsidhu@nhs.net E pididymitis is one of the most common urologic disorders and usually presents indolently with unilateral scrotal pain and swelling. The diagnosis is often based on clinical symptoms and examination, with resolution of symptoms after appropriate antibiotic therapy. If symptoms fail to resolve, with continuing pain a particular concern, sonography is performed to ascertain the presence of an indolent abscess or, more rarely, the presence of segmental infarction, a recognized but rare complication of severe epididymitis. 1 Both of these complications are readily identified on grayscale sonography, with color Doppler imaging aiding the delineation of an abscess within the inflamed epididymis or testis or focal segmental infarction within the testis. 2 With the advent of microbubble contrast agents, the technique of contrast-enhanced sonography has also been shown to be useful in identifying areas of segmental infarction 3 and abscess formation. 4 With segmental infarction, the clinical management is normally conservative, with resolution occurring over time, albeit with testicular atrophy often resulting. In the presence of a testicular or epididymal abscess, careful manipulation of antibiotic therapy will often result in resolution, but serial sonographic examinations are needed to confirm improvement or expedite surgical intervention. Global testicular infarction as a consequence of epididymitis is exceedingly rare, with only 4 cases described in the literature. 5 8 Global infarction is often a difficult diagnosis to establish unequivocally on sonography. The advent of contrast-enhanced sonography, with the ability to exquisitely show vascularity, may be a useful adjuvant for establishing the diagnosis by the American Institute of Ultrasound in Medicine

2 We report the occurrence of global testicular infarction in 2 patients with epididymitis clearly depicted on contrast-enhanced sonography, allowing immediate definitive surgical management to alleviate symptoms. Case Descriptions Case 1 A 55-year-old man with a history of resected colorectal cancer was seen in a preassessment clinic for stoma reversal. The patient had vague lower urinary tract symptoms for 3 days and was treated with appropriate antibiotics after isolation of Eschericha coli in the urine. After a 3-day course of antibiotics, he presented to the emergency department febrile and with increased pain in the right hemiscrotum and suprapubic region. On clinical examination, there was a tender erythematous swollen right hemiscrotum. Hematologic and biochemical screening revealed neutrophilia and a raised C-reactive protein level. A diagnosis of epididymitis was made, and the patient was admitted to hospital. On grayscale sonography, a thickened edematous right scrotal wall, a right-sided septated hydrocele, and an enlarged epididymis were identified. The underlying right testis was of uniform reflectivity, equivalent to the reflectivity of the left testis, with no focal lesions identified and no evidence of changes to suggest orchitis (Figure 1A). Color Doppler sonography showed an increased color signal in the epididymis, in keeping with inflammation, with no evidence of any color Doppler signal within the testis (Figure 1B). Further imaging with contrast-enhanced sonography (SonoVue, 4.8 ml; Bracco SpA, Milan, Italy) using a 9L linear transducer and an Acuson S2000 system (Siemens Medical Solutions, Mountain View, CA) was performed, showing an avidly enhancing right epididymis with no contrast enhancement of the entire right testis (Figure 1C). Based on the confirmation of the absence of blood flow on contrast-enhanced sonography, a diagnosis of global right testicular infarction secondary to epididymitis was suggested. The patient underwent immediate exploratory surgery, during with 50 ml of pus was drained, and a right orchidectomy was performed. Histologic examination revealed that the epididymis was inflamed with multiple microabscesses. Although macroscopically the right testis appeared normal, microscopically, ischemia of the entire testis was present but was unaffected by the adjacent inflammatory change (Figure 1, D and E). The patient had an uneventful recovery and remained well on follow-up. Case 2 A 64-year-old man with a history of type 2 diabetes mellitus, ischemic heart disease, and hypertension presented to his general practitioner with symptoms of left hemiscrotal swelling and pain of 2 days duration. The patient was treated with antibiotics, and sonography at the time showed inflammation of the left epididymis and normal appearances and vascularity in both testes. Persisting pain for 2 more days led to presentation to the emergency department, where he was found to have neutrophilia and a raised C-reactive protein level. A further sonographic examination showed increased vascularity in the epididymis again with normal appearances to the testis, but an associated hydrocele had developed. The patient was admitted to the hospital and, despite intravenous antibiotics, failed to improve. A third sonographic examination was performed. On grayscale imaging, the left epididymis was thickened with focal areas of low reflectivity identified. The underlying left testis was of uniform reflectivity, equivalent to the reflectivity of the right testis, with no focal lesions or evidence of orchitis. Surrounding the left testis was a septated hydrocele (Figure 2A). Color Doppler sonography showed an increased signal in the epididymis, in keeping with inflammation. There was no evidence of any color Doppler signal within the left testis (Figure 2B). Further imaging with contrast-enhanced sonography (SonoVue, 4.8 ml) using a 9L linear transducer and an Acuson S2000 system was performed, showing an avidly enhancing left epididymis with no contrast enhancement of the entire left testis (Figure 2C). Based on the confirmation of the absence of blood flow on contrast-enhanced sonography, a diagnosis of global left testicular infarction secondary to epididymitis was suggested. Surgery was expedited to remove the affected testis. Histologic findings showed an inflamed epididymis with multiple microabscesses and global infarction of the testis. There was inflammation and thickening of mediumsized vessels within the spermatic cord, which was thought to be secondary to vascular occlusion (Figure 2, D and E). The patient was treated with 6 days of intravenous antibiotics. He made an uncomplicated recovery and remained well on follow-up. Discussion The cases above highlight the use of contrast-enhanced sonography for assessment of vascularity within the testis in the light of apparently normal testicular appearances on grayscale sonography. In both cases, changes in the epididymis were seen; however, the parenchyma of the testis 176

3201jumv-online.qxp:Layout 1 12/20/12 9:06 AM Page 177 did not show any abnormality to suggest ischemia.

Imaging certainty with contrast-enhanced sonography allowed both patients A Figure 1. Case 1.

Scrotal skin thickening (long arrow) is present, and there is thickening of the epididymis (short arrows). A septated hydrocele is present.

C, Contrast-enhanced image showing no vascular flow within the entire testis, confirming the infarction of the right testis.

3 3201jumv-online.qxp:Layout 1 12/20/12 9:06 AM Page 177 did not show any abnormality to suggest ischemia. Color Doppler imaging identified a lack of flow within the testis, but contrast-enhanced sonography showed that the distinction of a lack of blood flow was much more obvious. In particular, contrast-enhanced sonography showed the complete absence of enhancing testicular parenchyma, indicating global testicular infarction. Imaging certainty with contrast-enhanced sonography allowed both patients A Figure 1. Case 1. A, Grayscale sonogram of the right testis showing uniform testicular reflectivity and a small surrounding hydrocele. Scrotal skin thickening (long arrow) is present, and there is thickening of the epididymis (short arrows). A septated hydrocele is present. B, Color Doppler image of the testis showing no depiction of a color signal within the entire testis. C, Contrast-enhanced image showing no vascular flow within the entire testis, confirming the infarction of the right testis. There is patchy enhancement of the epididymis with multiple foci of low reflectivity raising the possibility of small abscess formation. D, Epididymis with multiple microabscesses in the lumen, along with interstitial acute inflammation. The adjacent testis (bottom third) is infarcted (hematoxylin-eosin, original magnification 12.5). E. Infarcted testis showing intratubular and interstitial neutrophilic infiltrate and ghost germinal cells in the seminiferous tubules (hematoxylin-eosin, original magnification 100). B D C E 177

whereas the latter normally can be managed conservatively with recovery of the nonaffected testis.

A, Grayscale sonogram image of the left testis showing uniform testicular reflectivity and a sepated surrounding hydrocele.

B, Color Doppler image of the testis showing no depiction of a color signal within the entire testis.

4 3201jumv-online.qxp:Layout 1 12/20/12 9:06 AM Page 178 to have a confident diagnosis and to rapidly undergo surgery, preventing further infection and relieving symptoms. The distinction between global and segmental infarction is important: the former specifies surgical man- agement to prevent further complications, whereas the latter normally can be managed conservatively with recovery of the nonaffected testis. Acute segmental infarction itself is uncommon; causes include inflammation, trauma, and A Figure 2. Case 2. A, Grayscale sonogram image of the left testis showing uniform testicular reflectivity and a sepated surrounding hydrocele. Scrotal skin thickening (long arrow) is present, and there is thickening of the epididymis (short arrows). B, Color Doppler image of the testis showing no depiction of a color signal within the entire testis. C, Contrast-enhanced image showing no vascular flow within the entire testis, confirming the infarction of the left testis. An abscess is shown in the epididymis (arrow), which is seen to retain vascular enhancement despite the global infarction of the testis. D, Epididymis with multiple luminal microabscesses and an edematous acutely inflamed interstitium. The adjacent testis (bottom right) is infarcted (hematoxylin-eosin, original magnification 12.5). E, Intermediate arteries of the spermatic cord showing wall neutrophilic infiltrate and luminal thrombosis (secondary vasculitis; hematoxylin-eosin, original magnification 100). B C 178 D E

5 torsion. 9 In a series of 24 patients with segmental infarction, 58% had underlying epididymo-orchitis. 2 Although infarction is frequently indistinguishable clinically from other causes of acute scrotal pain, sonography can establish the diagnosis. On grayscale imaging, a segmental infarct appears as a hypoechoic intratesticular lesion, which may be round or wedge shaped. The shape of the infarction is based on the etiology: segmental arterial infarction in the testis results in a wedge-shaped lesion with the apex pointing toward the rete testis; conversely, venous infarction results in rounded lesions and is thought more often to be secondary to epididymitis. 2 With a rounded expansive focal testicular lesion, grayscale imaging may suggest that an area of segmental infarction represents a testicular germ cell tumor. 10 Color Doppler imaging plays an important role in this situation to enable the differentiation of a vascular tumor from an avascular infarction. Recent studies have showed a role for contrast-enhanced sonography in the depiction of areas of nonvascularized tissue in the testes in both segmental infarction 2,3 and avascular epidermoid tumors. 11 Any increase in vascularity may indicate the presence of a vascular tumor. 12 The mechanism of segmental infarction may be testicular inflammation and edema, causing compression against the relatively rigid tunica albuginea, preventing expansion, and raising the intratesticular pressure. These effects would likely result in vascular compression of small peripheral intratesticular vessels, resulting in segmental infarction. Global testicular infarction is classically caused by arterial insufficiency from compromise of the testicular artery as a result of spermatic cord torsion. Global infarction is rare after epididymitis, when recurrent pain and infection after the acute event cause clinical uncertainty and require further imaging. In the cases described here, grayscale imaging showed no focal or global testicular abnormality, making interpretation difficult and with the color Doppler examination indicating poor or absent blood flow to the testis. The addition of power Doppler imaging may have helped but would still not have been conclusive; 3% of healthy patients had false-negative findings on power Doppler studies of the testis. 13 In comparison, contrast-enhanced sonography will unequivocally show the presence or absence of vascularity. The cause of global infarction in epididymitis is uncertain, but it may be due to mixed arterial and venous insufficiency. A postulated mechanism is edema of the epididymal head, causing compression of the testicular veins, which lie medially, before the formation of the pampiniform plexus, resulting in venous congestion and multiple thromboses. This condition has been previously documented on histologic examinations in a study of testicular infarction after epididymitis, in which 17 of 18 samples showed completely occluded epididymal veins within the spermatic cord. 14 The appearance of an arterial component is also suggested by the higher peak systolic velocity found in patients with epididymitis 15 than encountered in the normal testicular artery. 16 The relative sparing of the epididymis from infarction may be due to an independent blood supply from that of the testis; the epididymis is supplied by the cremasteric artery and deferential artery. This state suggests a degree of testicular arterial constriction within the spermatic cord affecting mainly the more vulnerable lowresistance flow in the artery to the testis, rather than the arteries to the epididymis. 16 As a result of these two mechanisms, it can be postulated that global testicular infarction is of a mixed arterial and venous etiology. In conclusion, contrast-enhanced sonography has proved to be useful in unequivocally confirming the absence of blood flow to the testis in global testicular infarction resulting from epididymitis. If there remains doubt when examining the testis in patients with epididymitis, the addition of contrast-enhanced sonography will increase operator confidence and aid in the diagnosis of this rare complication of global infarction, expediting correct clinical management. References 1. Chin SC, Wu CJ, Chen A, Hsiao HS. Segmental hemorrhagic infarction of testis associated with epididymitis. J Clin Ultrasound1998; 26: Bilagi P, Sriprasad S, Clarke JL, Sellars ME, Muir GH, Sidhu PS. Clinical and ultrasound features of segmental testicular infarction: six-year experience from a single centre. Eur Radiol 2007; 17: Bertolotto M, Derchi LE, Sidhu PS, et al. Acute segmental testicular infarction at contrast-enhanced ultrasound: early features and changes during follow-up. AJR Am J Roentgenol 2011; 196: Lung PF, Jaffer OS, Sellars ME, Sriprasad S, Kooiman GG, Sidhu PS. Contrast-enhanced ultrasound in the evaluation of focal testicular complications secondary to epidiymitis. AJR Am J Roentgenol 2012; 199:W345 W Owen ER, Kitson JL, Green B. Venous infarction of the testis secondary to acute epididymitis. Br J Urol 1990; 65: Rencken RK, DuPlessis DJ, DeHaas LS. Venous infarction of the testes a cause of non-response to conservative therapy in epididymo-orchitis: a case report. South Afr Med J 1990; 78: Bird K, Rosenfield AT. Testicular infarction secondary to acute inflammatory disease: demonstration by B-scan ultrasound. Radiology 1984; 152: Sue SR, Pelucio M, Gibbs M. Testicular infarction in a patient with epididymitis. Acad Emerg Med 1998; 5:

6 9. Fernandez-Perez GC, Tardaguila FM, Velasco M, et al. Radiologic findings of segmental testicular infarction. AJR Am J Roentgenol 2005; 184: Sriprasad SI, Kooiman GG, Muir GH, Sidhu PS. Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound. Br J Radiol 2001; 74: Patel K, Sellars ME, Clarke JL, Sidhu PS. Features of testicular epidermoid cysts on contrast-enhanced sonography and real-time tissue elastography. J Ultrasound Med 2012; 31: Valentino M, Bertolotto M, Derchi L, et al. Role of contrast enhanced ultrasound in acute scrotal diseases. Eur Radiol 2011; 21: Albrecht T, Lotzof K, Hussain HK, Shedden D, Cosgrove DO, de Bruyn R. Power Doppler US of the normal prepubertal testis: does it live up to its promises? Radiology 1997; 203: Hourihane DO. Infected infarcts of the testis: a study of 18 cases preceded by pyogenic epididymoorchitis. J Clin Pathol 1970; 23: Brown JM, Hammers LW, Barton JW, et al. Quantitative Doppler assessment of acute scrotal inflammation. Radiology 1995; 197: Aziz ZA, Satchithananda K, Khan M, Sidhu PS. High-frequency color Doppler ultrasonography of the spermatic cord arteries: resistive index variation in a cohort of 51 healthy men. J Ultrasound Med 2005; 24:

Vikram Dogra, M.D. Professor of Radiology, Urology & BME Department of Imaging Sciences University Of Rochester Medical Center

Ultrasound of the Scrotum Vikram Dogra, M.D. Professor of Radiology, Urology & BME Department of Imaging Sciences University Of Rochester Medical Center Etiologies of Acute Scrotal Pain Epididymitis/Orchitis