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Segmental Testicular Infarction: Conservative Management is Feasible and Safe
european urology 53 (2008) 441–445
available at www.sciencedirect.com journal homepage: www.europeanurology.com
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 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 b
Article info
Abstract
Article history: Accepted March 17, 2007 Published online ahead of print on March 28, 2007
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.
Keywords: Infarction MRI Testis Ultrasonography
# 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. E-mail address: [email protected] (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
0302-2838/$ – see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2007.03.061
442
european urology 53 (2008) 441–445
Table 1 – Clinical and radiologic characteristics of all the patients with segmental testicular infarction No. Age, yr *
1 2 3* 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18* 19
52 51 31 34 60 38 36 30 25 72 53 30 35 32 49 42 27 28 51
Presentation
Echogenicity
Border
Size, mm
Side
Location
Shape
Left scrotal pain Left groin pain Left scrotal pain Left scrotal pain Right scrotal pain B/L scrotal pain Right scrotal pain B/L scrotal pain Right scrotal pain Right scrotal pain Right scrotal pain Left scrotal pain Right scrotal pain Right scrotal pain Right scrotal pain Right scrotal pain Incidental finding Left scrotal pain B/L scrotal pain
Hypoechoic Hypoechoic Hypoechoic Hypoechoic Mixed echogenicity Hyperechoic Hypoechoic Hypoechoic Hypoechoic Mixed echogenicity Hypoechoic Hypoechoic Mixed echogenicity Hypoechoic Hypoechoic Mixed echogenicity Hypoechoic Hypoechoic Hypoechoic
Well defined Ill defined Well defined Ill defined Ill defined Well defined Ill defined Well defined Well defined Ill defined Ill defined Ill defined Well defined Well defined Well defined Well defined Ill defined Well defined Well defined
14 19 26 13 20 18 Multiple small 17 24 22 19 18 24 17 15 16 18 14 20
Left Left Left Left Right B/L Right Right Right Right Right Left Right Right Right Right Right Left B/L
Midpole Upper pole Lower pole Lower pole Lower pole Upper pole Lower pole Midpole Upper pole Upper pole Upper pole Lower pole Upper pole Midpole Lower pole Lower pole Upper pole Lower pole Midpole
Oval Wedge Irregular Wedge Round Irregular Wedge Irregular Wedge Oval Wedge Wedge Wedge Wedge Wedge Oval Oval Wedge Wedge
Possible cause Vasculitisy Idiopathic Idiopathic Idiopathic Polycythaemia Idiopathic Orchitis Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic PANy 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).
european urology 53 (2008) 441–445
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.
443
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’’).
444
european urology 53 (2008) 441–445
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 T1weighted 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 the lesion in 9 and no change in 2 patients (Fig. 1). Associated systemic illness was absent in all patients.
european urology 53 (2008) 441–445
EU-ACME question Please visit www.eu-acme.org/europeanurology 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. Question: Which of the following statements is true with regards to segmental testicular infarction?
445
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.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
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 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 b
Article info
Abstract
Article history: Accepted March 17, 2007 Published online ahead of print on March 28, 2007
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.
Keywords: Infarction MRI Testis Ultrasonography
# 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. E-mail address: [email protected] (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
0302-2838/$ – see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2007.03.061
442
european urology 53 (2008) 441–445
Table 1 – Clinical and radiologic characteristics of all the patients with segmental testicular infarction No. Age, yr *
1 2 3* 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18* 19
52 51 31 34 60 38 36 30 25 72 53 30 35 32 49 42 27 28 51
Presentation
Echogenicity
Border
Size, mm
Side
Location
Shape
Left scrotal pain Left groin pain Left scrotal pain Left scrotal pain Right scrotal pain B/L scrotal pain Right scrotal pain B/L scrotal pain Right scrotal pain Right scrotal pain Right scrotal pain Left scrotal pain Right scrotal pain Right scrotal pain Right scrotal pain Right scrotal pain Incidental finding Left scrotal pain B/L scrotal pain
Hypoechoic Hypoechoic Hypoechoic Hypoechoic Mixed echogenicity Hyperechoic Hypoechoic Hypoechoic Hypoechoic Mixed echogenicity Hypoechoic Hypoechoic Mixed echogenicity Hypoechoic Hypoechoic Mixed echogenicity Hypoechoic Hypoechoic Hypoechoic
Well defined Ill defined Well defined Ill defined Ill defined Well defined Ill defined Well defined Well defined Ill defined Ill defined Ill defined Well defined Well defined Well defined Well defined Ill defined Well defined Well defined
14 19 26 13 20 18 Multiple small 17 24 22 19 18 24 17 15 16 18 14 20
Left Left Left Left Right B/L Right Right Right Right Right Left Right Right Right Right Right Left B/L
Midpole Upper pole Lower pole Lower pole Lower pole Upper pole Lower pole Midpole Upper pole Upper pole Upper pole Lower pole Upper pole Midpole Lower pole Lower pole Upper pole Lower pole Midpole
Oval Wedge Irregular Wedge Round Irregular Wedge Irregular Wedge Oval Wedge Wedge Wedge Wedge Wedge Oval Oval Wedge Wedge
Possible cause Vasculitisy Idiopathic Idiopathic Idiopathic Polycythaemia Idiopathic Orchitis Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic Idiopathic PANy 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).
european urology 53 (2008) 441–445
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.
443
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’’).
444
european urology 53 (2008) 441–445
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 T1weighted 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 the lesion in 9 and no change in 2 patients (Fig. 1). Associated systemic illness was absent in all patients.
european urology 53 (2008) 441–445
EU-ACME question Please visit www.eu-acme.org/europeanurology 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. Question: Which of the following statements is true with regards to segmental testicular infarction?
445
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.