Segmental Testicular Infarction: Conservative Management is Feasible and Safe

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1 european urology 53 (2008) available at journal homepage: Case Study of the Month Segmental Testicular Infarction: Conservative Management is Feasible and Safe Sanjeev Madaan a, Steven Joniau b, Katrien Klockaerts b, Liesbeth DeWever c, Evelyne Lerut d, Raymond Oyen c, Hendrik Van Poppel b, * a Department of Urology, St James University Hospital, Leeds, United Kingdom b Department of Urology, University Hospital Leuven, Leuven, Belgium c Department of Radiology, University Hospital Leuven, Leuven, Belgium d Department of Pathology, University Hospital Leuven, Leuven, Belgium Article info Article history: Accepted March 17, 2007 Published online ahead of print on March 28, 2007 Keywords: Infarction MRI Testis Ultrasonography Abstract 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. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, University Hospital Leuven, Herestraat 49, B-3000 Leuven, Belgium. address: hendrik.vanpoppel@uz.kuleuven.ac.be (H. Van Poppel). 1. 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 diagnosis. Imaging studies were reviewed by a uroradiologist (R.O.). Testicular tumour markers (a-fetoprotein, b-human chorionic gonadotropin, and lactic dehydrogenase) were tested in 10 cases. Three patients underwent orchidectomy because testicular tumour could not be excluded completely. All other patients /$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 442 european urology 53 (2008) Table 1 Clinical and radiologic characteristics of all the patients with segmental testicular infarction No. Age, yr Presentation Echogenicity Border Size, mm Side Location Shape Possible cause 1 * 52 Left scrotal pain Hypoechoic Well defined 14 Left Midpole Oval Vasculitis y 2 51 Left groin pain Hypoechoic Ill defined 19 Left Upper pole Wedge Idiopathic 3 * 31 Left scrotal pain Hypoechoic Well defined 26 Left Lower pole Irregular Idiopathic 4 34 Left scrotal pain Hypoechoic Ill defined 13 Left Lower pole Wedge Idiopathic 5 60 Right scrotal pain Mixed echogenicity Ill defined 20 Right Lower pole Round Polycythaemia 6 38 B/L scrotal pain Hyperechoic Well defined 18 B/L Upper pole Irregular Idiopathic 7 36 Right scrotal pain Hypoechoic Ill defined Multiple small Right Lower pole Wedge Orchitis 8 30 B/L scrotal pain Hypoechoic Well defined 17 Right Midpole Irregular Idiopathic 9 25 Right scrotal pain Hypoechoic Well defined 24 Right Upper pole Wedge Idiopathic Right scrotal pain Mixed echogenicity Ill defined 22 Right Upper pole Oval Idiopathic Right scrotal pain Hypoechoic Ill defined 19 Right Upper pole Wedge Idiopathic Left scrotal pain Hypoechoic Ill defined 18 Left Lower pole Wedge Idiopathic Right scrotal pain Mixed echogenicity Well defined 24 Right Upper pole Wedge Idiopathic Right scrotal pain Hypoechoic Well defined 17 Right Midpole Wedge Idiopathic Right scrotal pain Hypoechoic Well defined 15 Right Lower pole Wedge Idiopathic Right scrotal pain Mixed echogenicity Well defined 16 Right Lower pole Oval Idiopathic Incidental finding Hypoechoic Ill defined 18 Right Upper pole Oval Idiopathic 18 * 28 Left scrotal pain Hypoechoic Well defined 14 Left Lower pole Wedge PAN y B/L scrotal pain Hypoechoic Well defined 20 B/L Midpole Wedge Idiopathic B/L = bilateral; PAN = polyarteritis nodosa. * Had orchidectomy. y Histologic diagnosis. Fig. 1 Radiology findings in patient no. 8 show a sharply defined, hypoechoic lesion located centrally in the left testicle (A) on presentation, with absence of blood flow in the lesion (B). Follow-up ultrasounds at 6 wk (C) and 12 wk (D) show progressive regression of the lesion (arrow).

3 european urology 53 (2008) were treated conservatively and followed up with periodic ultrasonography or clinical evaluation or both. Patient age ranged from 25 to 72 yr with a median of 36 yr (Table 1). Eighteen patients presented with acute scrotum, without typical signs of testicular torsion, whereas one patient was incidentally found during work-up for infertility. Two patients had undergone surgery in the preceding 10 mo (bilateral inguinal hernia repair with mesh and ipsilateral radical nephrectomy, respectively). One patient was an intravenous drug abuser with AIDS with a previous history of orchitis. One patient suffered from polycythaemia. In the majority of patients no aetiologic cause could be found. Ultrasound of 14 patients (74%) showed a hypoechoic lesion (Figs. 1 and 2), and in 4 patients (21%) the lesion was of mixed echogenicity and in one (5%) a hyperechoic lesion was noted. In most cases (n = 11) infarcts were wedge-shaped with well-defined borders and no posterior acoustic enhancement. Maximum dimension of infarcts ranged from 15 to 24 mm. Seventeen patients had a solitary segmental infarct with 11 (58%) patients having right-sided infarct and 6 (32%) left-sided. In two patients (10%) infarcts were bilateral with one of them having multiple small infarcts. The infarct location was distributed throughout the testis without predilection for a given area. In seven patients the infarct was located in the upper pole, in four patients in the Fig. 2 Radiology findings in patient no. 12. On ultrasonography (A and B) the lesion is hypoechoic, well defined, rather nodular in shape and avasular. On precontrast T1-weighted axial magnetic resonance imaging (MRI) sequence with fat suppression (C) the infarct is isointense with some areas of hyperintensity within, suggestive of haemorrhage (arrow). On postcontrast T1-weighted MRI (D), the lesion is hypointense indicating no uptake of contrast in the lesion and the borders of the infarct clearly enhance ( enhancing rim ).

4 444 european urology 53 (2008) Fig. 3 (A) Polyarteritis nodosa: medium-sized artery showing severe intimal arteritis with margination and subendothelial localisation of numerous leukocytes, focally resulting in fibrinoid necrosis of the vessel wall. (Haematoxylin-eosin; original magnification T100). (B) Infarction of all structures in the testis. No recognisable vascular lesions or thrombosis. (Haematoxylin-eosin; original magnification T50). Fig. 4 Whole-mount orchidectomy specimens show segmental testicular infarct. midpole, and in eight patients in the lower pole. None of the patients had an associated haemorrhage seen on ultrasound examination. In 16 (84%) patients an avascular intratesticular area was identified on colour Doppler ultrasonography, whereas in three (16%) patients vascularity was markedly reduced (but not absent). MRI was performed in six patients. Typical MRI findings included a wedge-shaped hypodense area on T2-weighted images and absence of enhancement on dynamic contrast enhanced images. On precontrast T1-weighted MRI, the infarct was generally isointense and in one case there were some areas of hyperintensity within it suggestive of haemorrhage (Fig. 2C). Some patients also showed an enhanced rim on contrast enhancement of T1- weighted images (Fig. 2D). Three patients (16%) underwent orchidectomy because of a suspicion of a testicular tumour. Histologic examination revealed segmental infarction, which was associated with polyarteritis nodosa (n =1; Fig. 3A and 4A) and atypical vasculitis (n = 1), whereas the third patient showed segmental infarction without recognisable causative lesions (Fig. 3B and 4B). Follow-up was uneventful in all of these patients. Conservatively managed patients (n = 16) also had an uneventful course with resolution of symptoms in all cases. Follow-up ultrasonography at 6 12 wk was performed in 11 of 16 patients who were conservatively managed. It showed gradual regression of thelesionin9andnochangein2patients(fig. 1). Associated systemic illness was absent in all patients.

5 european urology 53 (2008) EU-ACME question Please visit 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. A. It appears as focal avascular area on colour Doppler ultrasound with normal remaining parenchyma. B. It is associated with raised testicular tumour markers. C. All the patients need emergency scrotal exploration. D. It is usually caused by testicular torsion. Question: Which of the following statements is true with regards to segmental testicular infarction?