Acute Gonadal Vein Thrombosis Secondary to Terminal Ileitis and Thrombophilia

Radiology Page Acute Gonadal Vein Thrombosis Secondary to Terminal Ileitis and Thrombophilia 40-year-old white male presented with severe abdominal pain 4 days after undergoing left hip replacement which increased and localized to the right lower quadrant and radiated to the right testicle. He experienced no nausea, vomiting, diarrhea or anorexia, and had no change in bowel habits. History was significant for protein S deficiency, venous thrombosis, Crohn’s disease and avascular necrosis of both hips. Medications included warfarin, oxycodone, steroid pulses and Remicade®. Vital signs were stable. On physical examination the right lower quadrant was tender on deep palpation and the right spermatic cord was tender throughout its palpable length. The testes were normal size and symmetrical with some tenderness on the right side. Most significantly during deep palpation of the right spermatic cord the patient reported sudden relief from pain, presumably as the clot was milked from the venous system. Hemoglobin/hematocrit was 11.2/42, white blood cell count was 12.7 with a left shift and an international normalized ratio of 3.0. Computerized tomography of the abdomen and pelvis without and with contrast medium revealed bilateral small intrarenal calcifications, appendicolith, a dilated right testicular vein and cord extending to the scrotum, and inflammation in an adjacent terminal ileal loop with its mesentery extended to the testicular vein (see figure). Scrotal ultrasound demonstrated symmetric size and normal flow in both testes. Treatment consisted of intravenous Toradol® for pain control and antiplatelet effect, intravenous fluids and ibuprofen. Review of the literature revealed reports of gonadal vein thrombosis in concert with thrombophilia and gastrointestinal inflammation.1 This case illustrates an interesting juxtaposition of the 2 conditions. Thrombosis was treated with ongoing warfarin anticoagulation, antiplatelet

A

0022-5347/08/1803-1124/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION

Inflamed and engorged right testicular vein just caudal to cecum

therapy and periodic manual compression. The patient recovered fully with this conservative approach. J. H. Schwartz, S. J. A. Sclafani, T. A. Glass and P. E. Sewell Department of Radiology Kings County Hospital Center/ SUNY Downstate School of Medicine Brooklyn, New York REFERENCE 1.

1124

Jain KA and Jeffrey RB Jr: Gonadal vein thrombosis in patients with acute gastrointestinal inflammation: diagnosis with CT. Radiology 1991; 180: 111.

Vol. 180, 1124, September 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.06.075