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Acute segmental testicular infarction: differentiation from tumour using high frequency colour Doppler ultrasound

Departments of ¹Urology and ²Radiology, Kings College Hospital, Denmark Hill, London SE5 9RS, UK

Correspondence: Dr Paul S Sidhu

	Abstract

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Segmental testicular infarction is rare, of variable aetiology but usually idiopathic. B-mode ultrasound may demonstrate a focal mass indistinguishable from a testicular tumour, with confirmation only achieved following surgery. We report a case of segmental testicular infarction presenting as a heterogeneous mass on B-mode ultrasound, confidently diagnosed as an area of infarction on high frequency colour Doppler ultrasound and proven on histology. The pre-operative differentiation of tumour from segmental infarction allows testis-sparing surgery.

	Introduction

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Acute testicular torsion is essentially a clinical diagnosis. Colour Doppler ultrasound (CDUS) imaging is useful in excluding acute epididymitis, when symptoms may overlap with acute testicular torsion [1]. Testicular tumours rarely present with pain, normally presenting with a slowly enlarging mass inadvertently discovered by the patient [2]. Ultrasound reliably demonstrates an intratesticular mass and CDUS may reveal a malignant vascular pattern [3]. The differential diagnosis of a patient with a painful testicular mass includes spermatic cord torsion, acute epididymo-orchitis and tumour. We describe a patient with pain and a focal testicular mass on B-mode ultrasound, where CDUS using high frequency Doppler techniques allowed the correct diagnosis of segmental infarction, rather than testicular tumour, to be made.

	Case report

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A 45-year-old male presented with a 3-day history of worsening right testicular pain. The referring doctor had treated the patient with antibiotics for epididymo-orchitis. The patient denied any other symptoms and his past medical history was unremarkable. Physical examination of the scrotum demonstrated tenderness of the inferior pole of the right testis and epididymis. The testis was normal in size, low lying and vertically placed. A clinical diagnosis of epididymo-orchitis was made, but scrotal ultrasound was requested in view of worsening symptoms despite antibiotic therapy. Scrotal ultrasound was performed on an Acuson Sequoia, using a 15L8W linear array colour Doppler probe (Acuson, Mountain View, CA), with imaging at 11.5 MHz (multifrequency capability of 8–13 MHz) on the standard "small parts testicle" setting. The ultrasound examination demonstrated a focally enlarged area of heterogeneous, predominantly low reflectivity in the lower aspect of the right testis (Figure 1). CDUS (colour Doppler set at 12.0 MHz) failed to show any colour flow within the low reflective abnormality but colour Doppler flow in the remaining testis was normal (Figure 2). There was no ultrasound evidence of epididymo-orchitis. The possibility of an acute area of segmental ischaemia or infarction rather than a tumour was raised because of the absence of colour Doppler signal in the abnormal area. Based on the B-mode ultrasound and CDUS findings, negative tumour markers and the importance of excluding spermatic cord torsion as a cause for the abnormality, surgery was undertaken. The scrotum was explored via a midline incision and the lower pole of the right testis was noted to be pale in colour. There was no torsion of the spermatic cord and the epididymis was normal. Excision biopsy of the abnormal area, rather than orchidectomy, was performed and the testes were fixed bilaterally to avoid any future possibility of spermatic cord torsion. Histology of the excised testicular tissue confirmed acute segmental testicular infarction.

View larger version (155K): [in this window] [in a new window]   Figure 1. B-mode ultrasound of the lower pole of the right testis demonstrating an enlarged, heterogeneous, low reflective area with an ill defined margin (arrows), suggesting the presence of a testicular tumour.

View larger version (136K): [in this window] [in a new window]   Figure 2. Colour Doppler ultrasound of the lower pole of the right testis showing lack of colour Doppler flow, strongly suggesting the presence of segmental ischaemia or infarction area rather than a vascular tumour.

	Discussion

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Scrotal ultrasound is a valuable investigation in distinguishing intratesticular and extratesticular pathology, although it cannot always exclude testicular torsion [1]. The B-mode ultrasound hallmark of global testicular ischaemia and infarction in the acute stage is an enlarged low reflective testis. This is followed by gradual shrinkage of the testis over time and an increase in reflectivity [10]. CDUS is useful in the evaluation of testicular torsion, where absence of colour flow to one testis in the presence of normal flow to the contralateral testis is diagnostic in the appropriate clinical situation [11]. Testicular tumours are usually seen as a focal area of varying reflectivity on B-mode ultrasound with inaccurate differentiation into benign and malignant lesions [12]. On CDUS, focal lesions of the testis, when larger than 16 mm, are associated with an increased and disordered blood flow [3].

Segmental testicular infarction, like global testicular infarction, should be characterized by poor or absent flow on CDUS. Previous reports on the B-mode ultrasound of segmental infarction have documented a variable appearance. The abnormality is usually that of a focal low reflective area with no posterior acoustic enhancement [4, 13, 14], although a high reflective abnormality has been documented [15]. In the present case, the B-mode ultrasound examination revealed a mixed reflective mass at the lower pole, with pockets of low reflectivity (Figure 1). There was focal expansion of the lower pole of the testis. A single previous report on the CDUS appearances of a segmental testicular infarction documented absence of colour flow in the presence of a focal area of increased reflectivity [15]. The affected testis was smaller than the contralateral testis, suggesting a chronic disease process, whereas the present case is an acute presentation.

Recent improvements in probe technology and colour Doppler sensitivity allow evaluation of intratesticular blood flow not previously documented. Whereas in the past the presence or absence of colour flow in the testis or disordered colour flow in a focal mass was all that could reliably be documented, blood vessels may now be clearly visualized and followed through the testis. In particular, malignant vascularity in focal testicular lesions can be clearly identified [16]. This is especially important in differentiating a malignant lesion from the rarer segmental infarction, as testis-preserving surgery can then be planned.

The general tendency when faced with testicular pain is towards immediate exploration. The present case demonstrates how newer technology and the appropriate use of CDUS may reliably diagnose segmental testicular infarction and, importantly, lead to a more conservative testis-sparing approach in the management of such patients.

Received for publication April 12, 2001. Revision received June 12, 2001. Accepted for publication June 22, 2001.

	References

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