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Tuberculous Epididymitis and Epididymo-Orchitis: Sonographic Findings
0022-534? /93/1501-002lS03.00/0 Vol. 150, 81-84,
THE JOURNAL OF UROLOGY
Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS: SONOGRAPHIC FINDINGS SEUNG H. KIM, HOW ARD M. POLLACK, KYUNG S. CHO, MATTHEW S. POLLACK AND MAN C. HAN From the Departments of Radiology, Seoul National University College of Medicine and Asan Medical Center, University of Ulsan, Korea, and Hospital of the University of Pennsylvania, Philadelphia and Easton Hospital, Easton, Pennsylvania
ABSTRACT
The findings at scrotal sonography in 10 patients with tuberculous epididymitis and in 2 with nontuberculous epididyrnitis are presented. In 6 patients with tuberculous epididymitis the testes were also involved (epididymo-orchitis). The most notable sonographic findings of tuberculous epididymitis were an enlarged epididymis, predominantly in the tail portion, and marked heterogeneity of the echo texture of the involved epididymis. Sonographic findings of associated testicular involvement consisted of a diffusely enlarged hypoechoic testis or ill defined focal intratesticular hypoechoic areas, or an irregular margin between the testis and epididymis. The sonographic findings encountered in patients with tuberculous epididymitis appear to be different from those encountered in nontuberculous epididymitis. Sonography might prove helpful in aiding the clinical distinction between these 2 forms of epididymitis and in demonstrating associated testicular involvement in tuberculous epididymitis. KEY WORDS:
epididymis, epididymitis, orchitis, tuberculosis
Although sonographic findings of epididymitis have been generally described as enlargement of the epididymis with decreased echogenicity, 1- 5 sonographic characteristics of tuberculous epididymitis and tuberculous epididymo-orchitis have been reported in only a few cases. 6 - 9 Differentiation of tuberculous epididymitis from nontuberculous epididymitis is important with regard to the management of a patient. 9 · 10 We characterize the sonographic findings within the scrotum in patients with tuberculous epididymitis and tuberculous epididymo-orchitis.
RESULTS
The sonographic findings encountered within the scrotum as well as other details concerning the 12 patients included in this study are summarized in the table. The intrascrotal lesion was on the right side in 5 patients and on the left side in 7. A draining sinus to the scrotal skin was present in 3 patients with tuberculous epididymitis (patients 1, 3 and 6). IVP was performed in 11 patients and findings attributable to tuberculosis were present in 4 with tuberculous epididymitis (a nonfunctioning left kidney with amorphous calcifications in patient 1, stenoses of infundibula and/or the ureter in patients 2 and 8, and irregularity of the caliceal margin in patient 5). In patient 4 with tuberculous epididymitis the IVP was normal but cystoscopic biopsy revealed tuberculosis of the bladder. Urine culture was performed in all patients and was positive for acidfast bacilli in patient 9. Evidence of old healed pulmonary tuberculosis was present on plain films of the chest in 3 patients with tuberculous epididymitis. Patient 6 with tuberculous epididymitis had the acquired immunodeficiency syndrome with related nephropathy but the organism obtained on culture of a scrotal sinus tract proved to be Mycobacterium tuberculosis and not M. avium-intracellulare, In 2 patients with nontuberculous epididymitis there was no evidence of tuberculosis on plain films of the chest or on an IVP. On sonography the involved epididymis was enlarged in all 10 patients with tuberculous epididymitis. Epididymal enlargement was diffuse in 7 patients (fig. 1), while in 3 it was limited to the tail (fig. 2). In the former 7 patients the involvement of the tail portion of the epididymis was more prominent than that in the head and body portions (figs. 1 and 3). In all 10 patients with tuberculous epididymitis echogenicity of the involved epididymis was generally lower than normal, although some hyperechoic areas were mixed. In contrast with tuberculous epididymitis, sonography showed a diffusely enlarged hypoechoic epididymis without tailpredominance in 1 of the 2 patients with nontuberculous epididymitis (fig. 4) and focal hypoechoic enlargement of the head portion of the epididymis with adjacent hydrocele with septation in the other (fig. 5). The echogenicity of the enlarged epididymis was relatively homogeneous in patients with nontuberculous epididymitis.
MATERIALS AND METHODS
The 12 patients (10 with tuberculous epididymitis and 2 with nontuberculous epididymitis) included in this study were referred for scrotal sonography because of unilateral scrotal swelling in 11 and infertility in 1. Among the 10 cases of tuberculous epididymitis 4 were collected at Seoul National University Hospital, 5 at the Hospital of the University of Pennsylvania and 1 at the Asan Medical Center. Two cases of nontuberculous epididymitis were from Seoul National University Hospital. The duration of scrotal swelling varied from 2 months to 20 years. In patient 7 the diagnosis of tuberculous scrotal abscess had been made 10 years previously, and he was treated with incision and drainage and antituberculous medications for 18 months. In other patients there were no prior diagnoses of or treatment for tuberculosis. Clinical impressions based on patient histories and the findings of physical examination were chronic epididymitis in 8 patients, tuberculous epididymitis in 3 and testicular tumor in 1. Scrotal sonography was performed with a real-time scanner with a 5, 7.5 or 10 MHz. transducer. Excretory urography (IVP) was also performed in 11 patients. All 12 patients underwent surgical exploration of the scrotum with histopathological confirmation. Epididymo-orchiectomy was performed in 6 patients and epididymectomy was done in 5. In patient 7 with tuberculous epididymitis only biopsy was performed at exploration. Histopathological diagnosis was tuberculous epididymitis in 4 patients, tuberculous epididymo-orchitis in 6 and nontuberculous epididymitis in 2. Accepted for publication December 23, 1992.
81
82
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
Findings in 10 patients with tuberculous epididymitis and/or epididymo-orchitis Pt. No.-Age-Side 1-45-Lt. 2-32-Lt. 3-66-Rt. 4-50-Rt. 5-43-Lt. 6-42-Rt.* 7-42-Lt. 8-40-Rt.
Sonographic Findings
Testicular Involvement at Operation
Operation
Epididymis
Testis
Diffusely enlarged, hypoechoic, heterogeneous Nodular enlargement of tail, hypoechoic, heterogeneous Diffusely enlarged, hypoechoic, heterogeneous
Diffusely enlarged, hypoechoic testis Normal
Lung, kidney (lt.)
Present
Lung, kidney (lt).
Absent
Epididymo-orchiectomy, nephrectomy Epididymectomy
Ill defined intratesticular hypoechoic lesions Diffusely enlarged hypoechoic testis Normal
Lung
Present
Epididymo-orchiectomy
Bladder
Present
Epididymo-orchiectomy
Kidney (bilat.), prostate
Absent
Epididymectomy
Normal
Absent
Absent
Epididymectomy
Normal
Absent
Absent
Open biopsy
Irregular margin between testis and epididymis Irregular margin between testis and epididymis Ill defined intratesticular hypoechoic lesions Normal
Kidney (lt.)
Present
Epididymo-orchiectomy
Absent
Present
Epididymo-orchiectomy
Prostate
Present
Epididymo-orchiectomy
Absent
Absent
Epididymectomy
Absent
Absent
Epididymectomy
Diffusely enlarged, hypoechoic, heterogeneous Nodular enlargement of tail, hypoechoic, heterogeneous Diffusely enlarged, hypoechoic, heterogeneous Nodular enlargement of tail, hypoechoic, heterogeneous Diffusely enlarged, hypoechoic, heterogeneous
9-80-Rt.
Diffusely enlarged, hypoechoic, heterogeneous
10-56-Lt.
Diffusely enlarged, hypoechoic, heterogeneous
11-52-Lt.
Diffusely enlarged, hypoechoic, homogeneous Enlarged head, hypoechoic, homogeneous
12-67-Lt.
Evidence of Tuberculosis in Other Organs
Normal
* Patient with acquired immunodeficiency syndrome. M. tuberculosis was cultured.
FIG. 1. Longitudinal scrotal sonograms of 45-year-old man with tuberculous epididymo-orchitis (patient 1). A, cranial portion of left hemiscrotum shows enlarged head (H) of epididymis and enlarged coarsely hypoechoic testis (T). Note small amount of hydrocele (arrow) between testis and epididymal head. B, mid portion of left hemiscrotum shows enlarged body of epididymis and testis (T). Note ill defined hypoechoic areas (arrows) within enlarged epididymis. C, caudal portion of left hemiscrotum reveals enlarged tail of epididymis (arrows) with marked heterogeneous echo texture. Focal area of marked hyperechogenicity (curved arrow) is possibly due to calcifications or draining sinus. Note diffusely enlarged testis ( T) with coarsely lessened echogenicity, and obliteration of interface between epididymis and testis. Epididymis and testis were confirmed to be involved by tuberculosis.
The ipsilateral testis appeared abnormal in 6 patients with tuberculous epididymitis, all of whom had diffuse testicular involvement confirmed at surgical and pathological examination. In patients with nontuberculous epididymitis the testis was normal on sonography and at operation. Sonographic findings of testicular involvement in patients with tuberculous epididymitis consisted of a diffusely enlarged hypoechoic testis in 2 (fig. 1), ill defined areas of intratesticular hypoechogenicity in 2 (fig. 3), and an irregular margin between the epididymis and testis in 2. A small amount of hydrocele was present in 3 patients with tuberculous epididymitis. In patient 12 with nontuberculous epididymitis an infected hydrocele was also noted. The presence of epididymal calcifications was suspected sonographically in 2 patients with tuberculous epididymitis but it was not confirmed pathologically. The physical and sonographic findings of the contralateral testis and epididymis were normal in all 12 patients.
DISCUSSION
Epididymitis is the most common intrascrotal inflammatory process and usually results from a retrograde spread of organisms from the prostatic urethra, prostate or seminal vesicle. 9 Tuberculous epididymitis, however, can occur not only from retrograde extension from the prostate and seminal vesicles but also from hematogenous dissemination, and there is some controversy about which of these 2 pathways is the more common.11 Tuberculous epididymitis is frequently associated with tuberculosis of the lung and urinary tract and, although bilateral involvement was the rule in the past, the disease as seen today is primarily unilateral. 11 In our study all 10 patients with tuberculous epididymitis had unilateral disease and evidence of tuberculosis in other organs was present in 7. Our 2 patients with nontuberculous epididymitis also had unilateral disease. Pathologically, the earliest lesions of tuberculous epididy-
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
FIG. 2. Longitudinal sonogram of left hemiscrotum in 32-year-old man with tuberculous epididymitis (patient 2) shows nodular hypoechoic mass (arrows) in tail of epididymis. Echogenicity of lesion is slightly heterogeneous. Testicle (T) is normal in size, shape and echogenicity.
FIG. 3. Longitudinal sonogram of right hemiscrotum (caudal portion) in 66-year-old man with tuberculous epididymo-orchitis (patient 3) shows markedly enlarged tail of epididymis (arrows) with heterogeneous echo texture. Note heterogeneous echo texture with ill defined hypoechoic areas within testicle (T).
mitis are discrete or conglomerate yellowish, necrotic areas in the tail portion of the epididymis (globus minor). While this early lesion may regress and heal, often with calcification, more commonly there is progressive extension of the process until the entire epididymis becomes involved. 12 Among our patients with tuberculous epididymitis, epididymal involvement was localized to the tail portion in 3. Although epididymal involvement was diffuse in the remaining 7 patients with tuberculous epididymitis the globus minor was more prominently involved than other portions of the epididymis in all of them. In 2 patients with nontuberculous epididymitis, however, epididymal enlargement was diffuse without tail predominance in 1 and enlargement was localized to the head portion in the other.
83
FIG. 4. Longitudinal sonogram of left hemiscrotum in 52-year-old man with nontuberculous epididymitis (patient 11) shows diffusely enlarged homogeneous hypoechoic epididymis (arrows).
FIG. 5. Longitudinal sonogram of left hemiscrotum in 67-year-old man with nontuberculous epididymitis (patient 12) reveals focal hypoechoic enlargement of head of epididymis (arrows) and adjacent loculated hydrocele with internal septa.
Only 2 cases of surgically and pathologically proved nontuberculous epididymitis were included in our series since patients with nontuberculous epididymitis are usually diagnosed clinically by improvement on antibiotics therapy. It has generally been reported that the sonographic findings of nontuberculous epididymitis usually consist of diffuse enlargement and a uniform decrease in echogenicity. 1- 5 However, in our 10 patients with tuberculous epididymitis there was prominent involvement of the tail of the epididymis together with marked heterogeneity of the echo texture of the lesion. We believe that these sonographic findings may be suggestive of tuberculous epididymitis as opposed to nontuberculous epididymitis. The marked sonographic heterogeneity in tuberculous epididymitis might be explained by the variety of pathological components, includ-
84
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
ing caseation necrosis and fibrosis, characterizing tuberculosis of the epididymis. 12 We believe that the lesion tends to be more heterogeneous in echo texture if there are calcifications or draining sinuses. In our study the lesion appeared more heterogeneous in patients with draining sinuses to the scrotal skin (patients 1 and 3, figs. 1 and 3) than in those without draining sinuses. Such sinus tracts are known to occur as a result of caseous abscesses reaching the skin. 13 When inflammation of the epididymis extends into the adjacent parenchyma of the testis, a diagnosis of epididymoorchitis is applicable. The sonographic findings of associated testicular involvement were diffuse enlargement with decreased echogenicity in most of the testis, or ill defined focal intratesticular hypoechogenicity or an irregular margin between the testis and epididymis. 4 • 5 • 14 • 15 Sonography was accurate in detecting associated testicular involvement in all of our patients. In summary, while we have collected cases of tuberculous epididymitis imaged with different transducers from various hospitals and only 2 cases of surgically and histologically proved nontuberculous epididymitis were included in this study, we nonetheless believe that it is reasonable to suggest that familiarity with the constellation of sonographic findings of tuberculous epididymitis described may be helpful in the differentiation of this condition from nontuberculous epididymitis. In the process detection of associated testicular involvement, differentiation of tuberculous epididymitis from nontuberculous epididymitis and selection of appropriate treatment, which is markedly different for the 2 disorders, could be facilitated. REFERENCES
1. Rifkin, M. D., Kurtz, A. B. and Goldberg, B. B.: Epididymis examined by ultrasound. Correlation with pathology. Radiology, 151: 187, 1984.
2. Leopold, G. R., Woo, V. L., Scheible, F. W., Nachtsheim D. and Gosink B. B.: High-resolution ultrasonography of scrotal pathology. Radiology, 131: 719, 1979. 3, Krone, K. D. and Carroll, B. A.: Scrotal ultrasound. Rad. Clin. N. Amer., 23: 121, 1985. 4. Hricak, H. and Jeffrey, R. B.: Sonography of acute scrotal abnormalities. Rad. Clin. N. Amer., 21: 595, 1983. 5. Rifkin, M. D., Kurtz, A. B., Pasto, M. E., Rubenstein, J. B., ColeBeuglet, C., Baltarowich, 0. and Goldberg, B. B.: The sonographic diagnosis of focal and diffuse infiltrating intrascrotal lesions. Urol. Rad., 6: 20, 1984. 6. Koyama, Y., Iigaya, T. and Saito, S.: Tuberculous epididymoorchitis. Urology, 31: 419, 1988. 7. Chung, T. and Harris, R. D.: Tuberculous epididymo-orchitis: sonographic findings. J. Clin. Ultrasound, 19: 367, 1991. 8. Heaton, N. D., Hogan, B., Michell, M., Thompson, P. and YatesBell, A. J.: Tuberculous epididymo-orchitis: clinical and ultrasound observations. Brit. J. Urol., 64: 305, 1989. 9. Mittemeyer, B. T., Lennox, K. W. and Borski, A. A.: Epididymitis: a review of 610 cases. J. Urol., 95: 390, 1966. 10. Cooke, D. I., Williams, C. E. and Fowler, R. C.: An evaluation of the role of the intravenous urogram in the management of patients with epididymo-orchitis. Clin. Rad., 38: 255, 1987. 11. Gow, J. G.: Genitourinary tuberculosis. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 23, p. 1045, 1986. 12. Mostofi, F. K. and Davis, C. J., Jr.: Male reproductive system and prostate. In: Anderson's pathology. Edited by J. M. Kissane and W. A. D. Anderson. St. Louis: The C. V. Mosby Co., chapt. 21, pp. 791-811, 1985. 13. Herbut, P. A.: Urological Pathology. Philadelphia: Lea & Febiger, p. 1067, 1952. 14. Benson, C. B., Doubilet, P. M. and Richie, J. P.: Sonography of the male genital tract. AJR, 153: 705, 1989. 15. Lentini, J. F., Benson, C. B. and Richie, J.P.: Sonographic features of focal orchitis. J. Ultrasound Med., 8: 361, 1989.
THE JOURNAL OF UROLOGY
Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS: SONOGRAPHIC FINDINGS SEUNG H. KIM, HOW ARD M. POLLACK, KYUNG S. CHO, MATTHEW S. POLLACK AND MAN C. HAN From the Departments of Radiology, Seoul National University College of Medicine and Asan Medical Center, University of Ulsan, Korea, and Hospital of the University of Pennsylvania, Philadelphia and Easton Hospital, Easton, Pennsylvania
ABSTRACT
The findings at scrotal sonography in 10 patients with tuberculous epididymitis and in 2 with nontuberculous epididyrnitis are presented. In 6 patients with tuberculous epididymitis the testes were also involved (epididymo-orchitis). The most notable sonographic findings of tuberculous epididymitis were an enlarged epididymis, predominantly in the tail portion, and marked heterogeneity of the echo texture of the involved epididymis. Sonographic findings of associated testicular involvement consisted of a diffusely enlarged hypoechoic testis or ill defined focal intratesticular hypoechoic areas, or an irregular margin between the testis and epididymis. The sonographic findings encountered in patients with tuberculous epididymitis appear to be different from those encountered in nontuberculous epididymitis. Sonography might prove helpful in aiding the clinical distinction between these 2 forms of epididymitis and in demonstrating associated testicular involvement in tuberculous epididymitis. KEY WORDS:
epididymis, epididymitis, orchitis, tuberculosis
Although sonographic findings of epididymitis have been generally described as enlargement of the epididymis with decreased echogenicity, 1- 5 sonographic characteristics of tuberculous epididymitis and tuberculous epididymo-orchitis have been reported in only a few cases. 6 - 9 Differentiation of tuberculous epididymitis from nontuberculous epididymitis is important with regard to the management of a patient. 9 · 10 We characterize the sonographic findings within the scrotum in patients with tuberculous epididymitis and tuberculous epididymo-orchitis.
RESULTS
The sonographic findings encountered within the scrotum as well as other details concerning the 12 patients included in this study are summarized in the table. The intrascrotal lesion was on the right side in 5 patients and on the left side in 7. A draining sinus to the scrotal skin was present in 3 patients with tuberculous epididymitis (patients 1, 3 and 6). IVP was performed in 11 patients and findings attributable to tuberculosis were present in 4 with tuberculous epididymitis (a nonfunctioning left kidney with amorphous calcifications in patient 1, stenoses of infundibula and/or the ureter in patients 2 and 8, and irregularity of the caliceal margin in patient 5). In patient 4 with tuberculous epididymitis the IVP was normal but cystoscopic biopsy revealed tuberculosis of the bladder. Urine culture was performed in all patients and was positive for acidfast bacilli in patient 9. Evidence of old healed pulmonary tuberculosis was present on plain films of the chest in 3 patients with tuberculous epididymitis. Patient 6 with tuberculous epididymitis had the acquired immunodeficiency syndrome with related nephropathy but the organism obtained on culture of a scrotal sinus tract proved to be Mycobacterium tuberculosis and not M. avium-intracellulare, In 2 patients with nontuberculous epididymitis there was no evidence of tuberculosis on plain films of the chest or on an IVP. On sonography the involved epididymis was enlarged in all 10 patients with tuberculous epididymitis. Epididymal enlargement was diffuse in 7 patients (fig. 1), while in 3 it was limited to the tail (fig. 2). In the former 7 patients the involvement of the tail portion of the epididymis was more prominent than that in the head and body portions (figs. 1 and 3). In all 10 patients with tuberculous epididymitis echogenicity of the involved epididymis was generally lower than normal, although some hyperechoic areas were mixed. In contrast with tuberculous epididymitis, sonography showed a diffusely enlarged hypoechoic epididymis without tailpredominance in 1 of the 2 patients with nontuberculous epididymitis (fig. 4) and focal hypoechoic enlargement of the head portion of the epididymis with adjacent hydrocele with septation in the other (fig. 5). The echogenicity of the enlarged epididymis was relatively homogeneous in patients with nontuberculous epididymitis.
MATERIALS AND METHODS
The 12 patients (10 with tuberculous epididymitis and 2 with nontuberculous epididymitis) included in this study were referred for scrotal sonography because of unilateral scrotal swelling in 11 and infertility in 1. Among the 10 cases of tuberculous epididymitis 4 were collected at Seoul National University Hospital, 5 at the Hospital of the University of Pennsylvania and 1 at the Asan Medical Center. Two cases of nontuberculous epididymitis were from Seoul National University Hospital. The duration of scrotal swelling varied from 2 months to 20 years. In patient 7 the diagnosis of tuberculous scrotal abscess had been made 10 years previously, and he was treated with incision and drainage and antituberculous medications for 18 months. In other patients there were no prior diagnoses of or treatment for tuberculosis. Clinical impressions based on patient histories and the findings of physical examination were chronic epididymitis in 8 patients, tuberculous epididymitis in 3 and testicular tumor in 1. Scrotal sonography was performed with a real-time scanner with a 5, 7.5 or 10 MHz. transducer. Excretory urography (IVP) was also performed in 11 patients. All 12 patients underwent surgical exploration of the scrotum with histopathological confirmation. Epididymo-orchiectomy was performed in 6 patients and epididymectomy was done in 5. In patient 7 with tuberculous epididymitis only biopsy was performed at exploration. Histopathological diagnosis was tuberculous epididymitis in 4 patients, tuberculous epididymo-orchitis in 6 and nontuberculous epididymitis in 2. Accepted for publication December 23, 1992.
81
82
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
Findings in 10 patients with tuberculous epididymitis and/or epididymo-orchitis Pt. No.-Age-Side 1-45-Lt. 2-32-Lt. 3-66-Rt. 4-50-Rt. 5-43-Lt. 6-42-Rt.* 7-42-Lt. 8-40-Rt.
Sonographic Findings
Testicular Involvement at Operation
Operation
Epididymis
Testis
Diffusely enlarged, hypoechoic, heterogeneous Nodular enlargement of tail, hypoechoic, heterogeneous Diffusely enlarged, hypoechoic, heterogeneous
Diffusely enlarged, hypoechoic testis Normal
Lung, kidney (lt.)
Present
Lung, kidney (lt).
Absent
Epididymo-orchiectomy, nephrectomy Epididymectomy
Ill defined intratesticular hypoechoic lesions Diffusely enlarged hypoechoic testis Normal
Lung
Present
Epididymo-orchiectomy
Bladder
Present
Epididymo-orchiectomy
Kidney (bilat.), prostate
Absent
Epididymectomy
Normal
Absent
Absent
Epididymectomy
Normal
Absent
Absent
Open biopsy
Irregular margin between testis and epididymis Irregular margin between testis and epididymis Ill defined intratesticular hypoechoic lesions Normal
Kidney (lt.)
Present
Epididymo-orchiectomy
Absent
Present
Epididymo-orchiectomy
Prostate
Present
Epididymo-orchiectomy
Absent
Absent
Epididymectomy
Absent
Absent
Epididymectomy
Diffusely enlarged, hypoechoic, heterogeneous Nodular enlargement of tail, hypoechoic, heterogeneous Diffusely enlarged, hypoechoic, heterogeneous Nodular enlargement of tail, hypoechoic, heterogeneous Diffusely enlarged, hypoechoic, heterogeneous
9-80-Rt.
Diffusely enlarged, hypoechoic, heterogeneous
10-56-Lt.
Diffusely enlarged, hypoechoic, heterogeneous
11-52-Lt.
Diffusely enlarged, hypoechoic, homogeneous Enlarged head, hypoechoic, homogeneous
12-67-Lt.
Evidence of Tuberculosis in Other Organs
Normal
* Patient with acquired immunodeficiency syndrome. M. tuberculosis was cultured.
FIG. 1. Longitudinal scrotal sonograms of 45-year-old man with tuberculous epididymo-orchitis (patient 1). A, cranial portion of left hemiscrotum shows enlarged head (H) of epididymis and enlarged coarsely hypoechoic testis (T). Note small amount of hydrocele (arrow) between testis and epididymal head. B, mid portion of left hemiscrotum shows enlarged body of epididymis and testis (T). Note ill defined hypoechoic areas (arrows) within enlarged epididymis. C, caudal portion of left hemiscrotum reveals enlarged tail of epididymis (arrows) with marked heterogeneous echo texture. Focal area of marked hyperechogenicity (curved arrow) is possibly due to calcifications or draining sinus. Note diffusely enlarged testis ( T) with coarsely lessened echogenicity, and obliteration of interface between epididymis and testis. Epididymis and testis were confirmed to be involved by tuberculosis.
The ipsilateral testis appeared abnormal in 6 patients with tuberculous epididymitis, all of whom had diffuse testicular involvement confirmed at surgical and pathological examination. In patients with nontuberculous epididymitis the testis was normal on sonography and at operation. Sonographic findings of testicular involvement in patients with tuberculous epididymitis consisted of a diffusely enlarged hypoechoic testis in 2 (fig. 1), ill defined areas of intratesticular hypoechogenicity in 2 (fig. 3), and an irregular margin between the epididymis and testis in 2. A small amount of hydrocele was present in 3 patients with tuberculous epididymitis. In patient 12 with nontuberculous epididymitis an infected hydrocele was also noted. The presence of epididymal calcifications was suspected sonographically in 2 patients with tuberculous epididymitis but it was not confirmed pathologically. The physical and sonographic findings of the contralateral testis and epididymis were normal in all 12 patients.
DISCUSSION
Epididymitis is the most common intrascrotal inflammatory process and usually results from a retrograde spread of organisms from the prostatic urethra, prostate or seminal vesicle. 9 Tuberculous epididymitis, however, can occur not only from retrograde extension from the prostate and seminal vesicles but also from hematogenous dissemination, and there is some controversy about which of these 2 pathways is the more common.11 Tuberculous epididymitis is frequently associated with tuberculosis of the lung and urinary tract and, although bilateral involvement was the rule in the past, the disease as seen today is primarily unilateral. 11 In our study all 10 patients with tuberculous epididymitis had unilateral disease and evidence of tuberculosis in other organs was present in 7. Our 2 patients with nontuberculous epididymitis also had unilateral disease. Pathologically, the earliest lesions of tuberculous epididy-
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
FIG. 2. Longitudinal sonogram of left hemiscrotum in 32-year-old man with tuberculous epididymitis (patient 2) shows nodular hypoechoic mass (arrows) in tail of epididymis. Echogenicity of lesion is slightly heterogeneous. Testicle (T) is normal in size, shape and echogenicity.
FIG. 3. Longitudinal sonogram of right hemiscrotum (caudal portion) in 66-year-old man with tuberculous epididymo-orchitis (patient 3) shows markedly enlarged tail of epididymis (arrows) with heterogeneous echo texture. Note heterogeneous echo texture with ill defined hypoechoic areas within testicle (T).
mitis are discrete or conglomerate yellowish, necrotic areas in the tail portion of the epididymis (globus minor). While this early lesion may regress and heal, often with calcification, more commonly there is progressive extension of the process until the entire epididymis becomes involved. 12 Among our patients with tuberculous epididymitis, epididymal involvement was localized to the tail portion in 3. Although epididymal involvement was diffuse in the remaining 7 patients with tuberculous epididymitis the globus minor was more prominently involved than other portions of the epididymis in all of them. In 2 patients with nontuberculous epididymitis, however, epididymal enlargement was diffuse without tail predominance in 1 and enlargement was localized to the head portion in the other.
83
FIG. 4. Longitudinal sonogram of left hemiscrotum in 52-year-old man with nontuberculous epididymitis (patient 11) shows diffusely enlarged homogeneous hypoechoic epididymis (arrows).
FIG. 5. Longitudinal sonogram of left hemiscrotum in 67-year-old man with nontuberculous epididymitis (patient 12) reveals focal hypoechoic enlargement of head of epididymis (arrows) and adjacent loculated hydrocele with internal septa.
Only 2 cases of surgically and pathologically proved nontuberculous epididymitis were included in our series since patients with nontuberculous epididymitis are usually diagnosed clinically by improvement on antibiotics therapy. It has generally been reported that the sonographic findings of nontuberculous epididymitis usually consist of diffuse enlargement and a uniform decrease in echogenicity. 1- 5 However, in our 10 patients with tuberculous epididymitis there was prominent involvement of the tail of the epididymis together with marked heterogeneity of the echo texture of the lesion. We believe that these sonographic findings may be suggestive of tuberculous epididymitis as opposed to nontuberculous epididymitis. The marked sonographic heterogeneity in tuberculous epididymitis might be explained by the variety of pathological components, includ-
84
TUBERCULOUS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
ing caseation necrosis and fibrosis, characterizing tuberculosis of the epididymis. 12 We believe that the lesion tends to be more heterogeneous in echo texture if there are calcifications or draining sinuses. In our study the lesion appeared more heterogeneous in patients with draining sinuses to the scrotal skin (patients 1 and 3, figs. 1 and 3) than in those without draining sinuses. Such sinus tracts are known to occur as a result of caseous abscesses reaching the skin. 13 When inflammation of the epididymis extends into the adjacent parenchyma of the testis, a diagnosis of epididymoorchitis is applicable. The sonographic findings of associated testicular involvement were diffuse enlargement with decreased echogenicity in most of the testis, or ill defined focal intratesticular hypoechogenicity or an irregular margin between the testis and epididymis. 4 • 5 • 14 • 15 Sonography was accurate in detecting associated testicular involvement in all of our patients. In summary, while we have collected cases of tuberculous epididymitis imaged with different transducers from various hospitals and only 2 cases of surgically and histologically proved nontuberculous epididymitis were included in this study, we nonetheless believe that it is reasonable to suggest that familiarity with the constellation of sonographic findings of tuberculous epididymitis described may be helpful in the differentiation of this condition from nontuberculous epididymitis. In the process detection of associated testicular involvement, differentiation of tuberculous epididymitis from nontuberculous epididymitis and selection of appropriate treatment, which is markedly different for the 2 disorders, could be facilitated. REFERENCES
1. Rifkin, M. D., Kurtz, A. B. and Goldberg, B. B.: Epididymis examined by ultrasound. Correlation with pathology. Radiology, 151: 187, 1984.
2. Leopold, G. R., Woo, V. L., Scheible, F. W., Nachtsheim D. and Gosink B. B.: High-resolution ultrasonography of scrotal pathology. Radiology, 131: 719, 1979. 3, Krone, K. D. and Carroll, B. A.: Scrotal ultrasound. Rad. Clin. N. Amer., 23: 121, 1985. 4. Hricak, H. and Jeffrey, R. B.: Sonography of acute scrotal abnormalities. Rad. Clin. N. Amer., 21: 595, 1983. 5. Rifkin, M. D., Kurtz, A. B., Pasto, M. E., Rubenstein, J. B., ColeBeuglet, C., Baltarowich, 0. and Goldberg, B. B.: The sonographic diagnosis of focal and diffuse infiltrating intrascrotal lesions. Urol. Rad., 6: 20, 1984. 6. Koyama, Y., Iigaya, T. and Saito, S.: Tuberculous epididymoorchitis. Urology, 31: 419, 1988. 7. Chung, T. and Harris, R. D.: Tuberculous epididymo-orchitis: sonographic findings. J. Clin. Ultrasound, 19: 367, 1991. 8. Heaton, N. D., Hogan, B., Michell, M., Thompson, P. and YatesBell, A. J.: Tuberculous epididymo-orchitis: clinical and ultrasound observations. Brit. J. Urol., 64: 305, 1989. 9. Mittemeyer, B. T., Lennox, K. W. and Borski, A. A.: Epididymitis: a review of 610 cases. J. Urol., 95: 390, 1966. 10. Cooke, D. I., Williams, C. E. and Fowler, R. C.: An evaluation of the role of the intravenous urogram in the management of patients with epididymo-orchitis. Clin. Rad., 38: 255, 1987. 11. Gow, J. G.: Genitourinary tuberculosis. In: Campbell's Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 23, p. 1045, 1986. 12. Mostofi, F. K. and Davis, C. J., Jr.: Male reproductive system and prostate. In: Anderson's pathology. Edited by J. M. Kissane and W. A. D. Anderson. St. Louis: The C. V. Mosby Co., chapt. 21, pp. 791-811, 1985. 13. Herbut, P. A.: Urological Pathology. Philadelphia: Lea & Febiger, p. 1067, 1952. 14. Benson, C. B., Doubilet, P. M. and Richie, J. P.: Sonography of the male genital tract. AJR, 153: 705, 1989. 15. Lentini, J. F., Benson, C. B. and Richie, J.P.: Sonographic features of focal orchitis. J. Ultrasound Med., 8: 361, 1989.