Segmental testicular ischaemia: presentation, management and follow‐up

Abstract

Segmental infarction of the testis is a rare event. Less than 40 cases have been reported in the literature and its aetiology remains largely unknown. The diagnosis is challenging and its identification crucial as partial ischaemia is frequently confused with testicular tumours and unnecessarily treated with orchiectomy. The objectives of this study are to: (i) raise awareness of this rare condition, (ii) provide the distinctive clinical and radiological features enabling pre-operative diagnosis, (iii) promote appropriate screening of causative factors and (iv) propose an alternative management approach to avoid surgery and preserve fertility. We describe three cases of partial testicular ischaemia in men presenting with reduced sperm quality. The cases demonstrate the ultrasound and magnetic resonance imaging appearance of testicular ischaemia. The surveillance strategy adopted for these lesions indicates that over 2 years of follow-up, marginal changes in the lesions can occur. Histology revealed that infiltration by stromal cells, leucocytes and macrophages is responsible for the remodelling of these lesions. Screening of risk factors for thromboembolism revealed that all patients carried a methylenetetrahydrofolate reductase 677C-->T (MTHFR) mutation in a gene involved in folate metabolism, and either borderline or elevated homocysteine levels. Distinctive features permit the pre-operative diagnosis of segmental testicular ischaemia. There are sufficient data to assert that a surveillance strategy is safe and feasible. We speculate that the defects in folate metabolism may pre-dispose individuals to the development of testicular infarction and infertility.

Acute Segmental Testicular Infarction at Contrast-Enhanced Ultrasound: Early Features and Changes During Follow-Up

“…We found gray-scale and color Doppler features of segmental testicular infarction similar to those described in other studies [1,5,9,11,[14][15][16][17]. The spectrum of findings differed depending on the time between the onset of testicular pain and the ultrasound examination.…”

Segmental testicular infarction: report of seven new cases and literature review

“…These include acute epididymo-orchitis, scrotal trauma, inguinal hernia repair, vasculitis, sickle cell disease, torsion, and hypercoagulable states [1-3, 6, 7]. Additionally, one publication suggested that a specific mutation in a gene, methylenetetrahydrofolate reductase 677C, is found in patients with segmental testicular infarction [8]. When related to torsion, it is usually not a complete torsion, but involves either torsiondetorsion, or lesser degrees of twisting for prolonged periods of time [6].…”

Differential Diagnosis of Nonpalpable Testicular Lesions: Qualitative and Quantitative Contrast-enhanced US of Benign and Malignant Testicular Tumors

“…In both cases, their stable, small testicular lesion was associated with distant metastasis (one pulmonary and one retroperitoneal) diagnosed at follow-up, confirming that a total body scan is necessary in patients for whom a surveillance strategy is adopted (24). A further improvement of the reported accuracy could also potentially be obtained by integrating contrast-enhanced US with other techniques such as elastosonography and MR imaging (25,31,32).…”

“…In agreement with the findings of Lock et al (14) and Huang and Sidhu (12), both benign and malignant tumors tended to enhance strongly. This helps in the differential diagnosis against nonneoplastic lesions (ischemia, abscesses, cysts) (24,25). However, the contrast material dynamics can vary in different histologic groups.…”