SEGMENTAL TESTICULAR INFARCT

Image Presentation

ACUTE SEGMENTAL TESTICULAR INFARCT -  mimic like a tumor on grayscale ultrasound , and color Doppler ultrasound  can clearly differentiate it from tumor .

Abstract

Segmental testicular infract is very uncommon pathology , & involves variable etiology , but commonly idiopathic . On grayscale ultrasound it appears as a focal inhomogenic mass which is difficult to be differentiated  from testicular tumor . However high resolution color Doppler ultrasound confidently diagnose it as an area of infarction & allows testis sparing surgery .

Introduction

Color Doppler ultrasound ( CDUS ) is very useful modality in evaluation of acute scrotum , and to  differentiate  between epididymoorchitis & torsion when symptoms may overlap  ( 2 ) .  The common conditions causing a painful scrotum  includes torsion & epididymoorchitis ,  and rarely tumor . Testicular tumor normally presents as a slow growing mass , rarely painful , and incidently discorved by the patient( 3 ) . On grayscale ultrasound tumor appears as an inhomogenic focal mass and CDUS demonstrates internal vascularity with malignant vascular pattern ( 4 ) . I present a case with painful testicular focal inhomogenic mass on grayscale ultrasound where CDUS allowed the diagnosis of segmental testicular infarction , rather than a testicular tumor , to be labelled .

Case report

A 46 years old man presented with a history of increasing right testicular pain for few days . The case was already  on antibiotics for presumed epididymoorchitis , however with no significant relief . On physical examination there was tenderness at the upper pole of right testis and epididymis , and a clinical diagnosis of epididymoorchitis was made.  In view of no relief in symptoms , the scrotal sonography was requested . Scrotal sonography was performed on GE – Logiq 400 pro  ultrasound system , using 8 to 11 MHZ. linear probe with small parts setting . The grayscale ultrasound examination revealed a focal enlarged inhomogenic area of  iso to hypoechoic echogenisity  at upper pole of right testis ( figure 1 ) . The CDUS failed to show any color flow signals within the mass but color flow signals were noted normal in rest of the testicular parenchyma ( figure 2 ) .  No any calcific focus or cystic change noted within lesion . No any other ultrasound evidence of epididymoorchitis was present . The possibility of an acute segmental testicular infract was made rather then a tumor because of absent color doppler signals in the focal abnormal area . The patient had normal complete blood count , and  was advised surgical exporation  by the referring doctor to exclude spermatic cord torsion as a cause for the abnormality . But  the patient  had refused for surgery , and  was  allowed to continue symptomatic medical treatment for some days .

After few weeks the referring doctor was contacted for follow up details of this case , and he ( referring doctor )  confirmed that the patient improved gradually and became symptom free with some residual testicular atrophy . The patient  was advised a review ultrasound  but he did not turn up .  

            

Discussion

Total testicular infarction is usually seen after torsion of spermatic cord , severe epididymoorchitis or trauma ( 2 ) . Segmental testicular infarction  is a rare entity and usually diagnosed by postorchidectomy histopathology  ( 5, 6 ) . The predisposing factors to segmental infarction  includes polycythemia ( 7 ) , intimal fibroplasia of spermatic artery ( 8 ) , sickle cell disease ( 9 ) , hypersensitivity angitits ( 10 ) and trauma , although most of the cases are idiopathic in origin ( 7 ) , as in this case . S. Sriprasad  et. al. reported a case  in BJR in 2001  with the same grayscale and CDUS  findings , which was proved to be a segmental testicular infarct histopathologically .  Scrotal sonography is valuable tool in differential diagnosis  of acute scrotum , & clearly differentiate  testicular torsion & infarct with high accuracy . In epididymoorchitis the testis and epididymis shows hyperemia , whereas absent or poor vascularity seen in torsion and infarct . The B- mode findings in acute testicular ischemia are enlarged and hypoechoic testis . CDUS helps to diagnose testicular torsion  where absent or poor blood flow noted in symptomatic testis  , and normal blood flow in contralateral  testis . The testicular tumors are usually seen as focal inhomogenic  or variable echotexture  masses with disordered / malignant internal vascularity on Doppler  ( 13 ) . On color Doppler , focal lesions larger than 16 mm , usually show raised and disordered blood flow ( 4 ) . Segmental testicular infarct also appears as focal mass of variable echogenicity with absent blood flow on Doppler ( 1 ) .  However cases with focal area of increased echogenicity  and poor or absent blood flow on CDUS were also reported and documented  in  segmental infarct ( 16 ) . This case showed  focal inhomogenic or variable echotexture mass at upper pole right testis with absent blood flow signals on CDUS , closely resembles the case reported by S. Sriprasad  et. al. . There was  focal enlargement of upper pole of testis , which may indicate acute nature of  the disease , because in chronic process the affected testis may appear small or shrunken ( 16 ) .  So with recent advances in probe technology and color Doppler sensitivity , it is  possible to document Intratesticular blood flow as well as vasculature pattern in a better way , which is  important particularly in differentiating a malignant mass from segmental infarction , as both appears identical on B – mode ultrasound , and thereby helpful in  suggesting a treatment  planning ( testis sparing & conservative management ) .

  

                   ( Figure 1 )    - Sagittal US image shows inhomogenic iso to hypoechoic mass like lesion 

                                         ( two small arrows ) involving upper pole of right testis    

   

               ( Figure 2 )  -  Color Doppler Us image of same testis shows absent color flow signals in the                                    abnormal area     s/o infarct , and normal blood flow signals in rest of the testis .

 PS ; The case study is based on imaging features & review literature , and intended for medical professionals & imaging specialists for academic purpose .

Referrences

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