Testicular Hemorrhage, Necrosis, and Vasculopathy

Abstract

We report 30 cases of testicular hemorrhage and/or necrosis with associated vascular damage that caused clinical concern for a neoplasm and that raised the question of a vasculitis syndrome on pathologic examination. The patients were 12 to 66 years old (median, 33 y) and presented with pain (n=15), mass (n=12), or both (n=2); 1 case had no available clinical information. Ultrasonographic interpretations included a neoplasm in the differential diagnoses in 14 of 18 cases in which this information was available, and most (n=24) had orchiectomy because of this possibility. Only 4 were clinically suspected to represent testicular infarction. Circumscribed, hemorrhagic lesions occurred in 10 cases, less demarcated hemorrhagic foci in 5, and discrete nodules or ill-defined foci of varying color and consistency in the remainder. No clear testicular lesion was described in 2, with 1 of these having a "dusky" appearance. On microscopic examination all but 1 case showed damaged blood vessels (vasculopathy), with either associated hemorrhage/hematoma (n=24) and/or areas of parenchymal necrosis (n=21). One case showed only segmental tubular atrophy with interstitial inflammation and vasculopathy; no infarct or hemorrhage was identified. A variety of vascular changes was identified, including prominent intimal thickening in arteries (n=22) and fibrinoid change in both arteries (n=5) and vessels of indeterminate type (n=8). Medial fibrosis was present in veins (n=12) and vessels of indeterminate type (n=4), whereas thrombi (remote, recanalized, and/or recent) occurred in arteries (n =7), veins (n=9), and vessels of indeterminate type (n=11). Dilated, blood-filled vessels were present in the testis and/or paratestis in 15 cases. In addition, 7 cases showed arteriolar hyalinization, and 19 had inflammation of blood vessels. The latter was lymphohistiocytic and mostly light but occasionally prominent (n=5). Interstitial inflammation was seen adjacent to damaged testicular parenchyma in all 30 cases. Clinical follow-up in 20 patients (4 to 131 mo, mean 38 mo) showed no evidence of recurrence in the contralateral testis or later development of systemic vasculitis. The histologic findings were compared with those in 11 orchiectomies resected for clinical acute torsion. All clinical acute torsion cases showed both parenchymal and fibrinoid vascular necrosis, and 10 had hemorrhage/hematoma; they lacked vasculitis, interstitial inflammation, and chronic vascular changes. Testicular vasculopathy, characterized by acute and chronic vascular injury, commonly occurs in testes with parenchymal hemorrhage and necrosis that clinically mimic a tumor. It shares the acute features of recent torsion but also has findings indicative of chronic injury. Testicular vasculopathy is most likely a result of chronic intermittent torsion that leads to localized hemorrhage/necrosis and should be distinguished from cases of systemic vasculitis given the significantly different clinical implications.

Segmental Testicular Infarction, an Underdiagnosed Entity: Case Report with Histopathologic Correlation and Review of the Diagnostic Features

“…The unique anatomical location of testis, lying within an external body sac while hanging from its vascular pedicle, makes it hypermobile and prone to vascular accidents compared to other body organs. Congenital abnormalities like “bell-clapper” deformity with abnormal attachment of the testis to its muscular and facial layers increase the chance of testicular ischemic events [ 1 , 2 ]. Compression of the spermatic cord as a result of torsion leads to vascular insufficiency and testicular infarction.…”

Focal non granulomatous orchitis in a patient with Crohn’s disease

“…However, microscopic description lacked all the following features as compiled by Kao et al , evoking such a cause, i.e. segmental haemorrhage, damaged blood vessels and ghost outlines of the tubules [ 13 ].…”

Chronic Testicular Vasculopathy Presenting as Acute Testicular Torsion and Mimicking Localized Vasculitis

“…Even though cases of localized vasculitis limited to the testes have been reported, experts in the field have questioned the true existence of such cases. 5 Moreover, it is very unusual for the testes to be the primary or initial site of involvement and patients with localized testicular vasculitis may present with a testicular mass-like lesions in the absence of systemic symptoms and laboratory abnormalities of vasculitis. 5,9,10…”

“…5 Moreover, it is very unusual for the testes to be the primary or initial site of involvement and patients with localized testicular vasculitis may present with a testicular mass-like lesions in the absence of systemic symptoms and laboratory abnormalities of vasculitis. 5,9,10…”

“…Moreover, in the absence of neoplastic process, it is exceedingly rare to encounter localized vasculitis involving testicular vasculature as an initial manifestation in adults without systemic disease and the vasculopathic changes as described by Kao et al are more likely the cause of the acute presentation. [3][4][5] Overall, testicular hemorrhage and necrosis with acute neutrophilic and chronic lymphohistiocytic infiltrate in the wall of the intratesticular or paratesticular vessels as well as vessel thrombi and red blood cell extravasation suggest a vasculitis process. Herein, we report our unique findings of a testicular vasculopathy in an adult male, who clinically presented as acute testicular torsion necessitating emergency orchidectomy and histologically mimicking localized vasculitis.…”