Case Study of the Month

Segmental Testicular Infarction: ConservativeManagement 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,*aDepartment of Urology, St James University Hospital, Leeds, United KingdombDepartment of Urology, University Hospital Leuven, Leuven, BelgiumcDepartment of Radiology, University Hospital Leuven, Leuven, BelgiumdDepartment of Pathology, University Hospital Leuven, Leuven, Belgium

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Article info

Article history:Accepted March 17, 2007Published online ahead ofprint on March 28, 2007

Keywords:InfarctionMRITestisUltrasonography

0302-2838/$ – see back matter # 2007 European A

Abstract

Segmental testicular infarction is a rare cause of acute scrotum. Itsaetiology is not well defined and it can be clinically confused with atesticular tumour. Because the differential diagnosis between segmentaltesticular infarction and testicular tumour can be difficult, most authorsin the past recommended surgery. Imaging plays an important role in thepreoperative diagnosis, with a colour Doppler ultrasonography as theinvestigation of choice although magnetic resonance imaging (MRI) canbe useful in doubtful cases. The objective of this retrospective study wasto describe the radiologic findings and the outcome of conservativemanagement in a single-centre experience of 19 cases of segmentaltesticular 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.E-mail address: hendrik.vanpoppel@uz.kuleuven.ac.be (H. Van Poppel).

1. Case report

The database of men presenting with acute scrotumbetween October 1997 and June 2006 was reviewedand electronic files of all the patients diagnosed withsegmental testicular infarction were selected fordetailed evaluation. In 19 patients presenting withacute testicular pain the diagnosis of segmentaltesticular infarction was made on colour Doppler

ssociation of Urology. Publis

ultrasonography or on histologic examination aftersurgery. Magnetic resonance imaging (MRI) wasperformed 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 dehy-drogenase) were tested in 10 cases. Three patientsunderwent orchidectomy because testicular tumourcould not be excluded completely. All other patients

hed by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2007.03.061

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 Vasculitisy

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

10 72 Right scrotal pain Mixed echogenicity Ill defined 22 Right Upper pole Oval Idiopathic

11 53 Right scrotal pain Hypoechoic Ill defined 19 Right Upper pole Wedge Idiopathic

12 30 Left scrotal pain Hypoechoic Ill defined 18 Left Lower pole Wedge Idiopathic

13 35 Right scrotal pain Mixed echogenicity Well defined 24 Right Upper pole Wedge Idiopathic

14 32 Right scrotal pain Hypoechoic Well defined 17 Right Midpole Wedge Idiopathic

15 49 Right scrotal pain Hypoechoic Well defined 15 Right Lower pole Wedge Idiopathic

16 42 Right scrotal pain Mixed echogenicity Well defined 16 Right Lower pole Oval Idiopathic

17 27 Incidental finding Hypoechoic Ill defined 18 Right Upper pole Oval Idiopathic

18* 28 Left scrotal pain Hypoechoic Well defined 14 Left Lower pole Wedge PANy

19 51 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).

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were treated conservatively and followed up withperiodic ultrasonography or clinical evaluation orboth.

Patient age ranged from 25 to 72 yr with a medianof 36 yr (Table 1). Eighteen patients presented withacute scrotum, without typical signs of testiculartorsion, whereas one patient was incidentally foundduring work-up for infertility. Two patients hadundergone surgery in the preceding 10 mo (bilateralinguinal hernia repair with mesh and ipsilateralradical nephrectomy, respectively). One patient wasan intravenous drug abuser with AIDS with aprevious history of orchitis. One patient sufferedfrom polycythaemia. In the majority of patients noaetiologic cause could be found.

Fig. 2 – Radiology findings in patient no. 12. On ultrasonograph

nodular in shape and avasular. On precontrast T1-weighted ax

suppression (C) the infarct is isointense with some areas of hyp

postcontrast T1-weighted MRI (D), the lesion is hypointense ind

of the infarct clearly enhance (‘‘enhancing rim’’).

Ultrasound of 14 patients (74%) showed a hypoe-choic lesion (Figs. 1 and 2), and in 4 patients (21%) thelesion was of mixed echogenicity and in one (5%) ahyperechoic lesion was noted. In most cases (n = 11)infarcts were wedge-shaped with well-definedborders and no posterior acoustic enhancement.Maximum dimension of infarcts ranged from 15 to24 mm. Seventeen patients had a solitary segmentalinfarct with 11 (58%) patients having right-sidedinfarct and 6 (32%) left-sided. In two patients (10%)infarcts were bilateral with one of them havingmultiple small infarcts. The infarct location wasdistributed throughout the testis without predilec-tion for a given area. In seven patients the infarctwas located in the upper pole, in four patients in the

y (A and B) the lesion is hypoechoic, well defined, rather

ial magnetic resonance imaging (MRI) sequence with fat

erintensity within, suggestive of haemorrhage (arrow). On

icating no uptake of contrast in the lesion and the borders

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.

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midpole, and in eight patients in the lower pole.None of the patients had an associated haemor-rhage seen on ultrasound examination. In 16 (84%)patients an avascular intratesticular area wasidentified on colour Doppler ultrasonography,whereas in three (16%) patients vascularity wasmarkedly reduced (but not absent).

MRI was performed in six patients. Typical MRIfindings included a wedge-shaped hypodense areaon T2-weighted images and absence of enhance-ment on dynamic contrast enhanced images. Onprecontrast T1-weighted MRI, the infarct was gen-erally isointense and in one case there were someareas of hyperintensity within it suggestive ofhaemorrhage (Fig. 2C). Some patients also showedan enhanced rim on contrast enhancement of T1-weighted images (Fig. 2D).

Three patients (16%) underwent orchidectomybecause of a suspicion of a testicular tumour.Histologic examination revealed segmental infarc-tion, which was associated with polyarteritisnodosa (n = 1; Fig. 3A and 4A) and atypicalvasculitis (n = 1), whereas the third patient showedsegmental infarction without recognisable causa-tive lesions (Fig. 3B and 4B). Follow-up wasuneventful in all of these patients. Conservativelymanaged patients (n = 16) also had an uneventfulcourse with resolution of symptoms in all cases.Follow-up ultrasonography at 6–12 wk was per-formed in 11 of 16 patients who were conserva-tively managed. It showed gradual regression ofthe lesion in 9 and no change in 2 patients (Fig. 1).Associated systemic illness was absent in allpatients.

EU-ACME question

Please visit www.eu-acme.org/europeanurologyto answer the below EU-ACME question on-line(the EU-ACME credits will be attributed automa-tically). The answer will be given in Case Study ofthe Month: Part 2, which will be published in nextmonth’s issue of European Urology.

Question:Which of the following statements is true with

regards to segmental testicular infarction?

A. It appears as focal avascular area on colourDoppler ultrasound with normal remainingparenchyma.

B. It is associated with raised testicular tumourmarkers.

C. All the patients need emergency scrotalexploration.

D. It is usually caused by testicular torsion.

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