Complete testicular infarction secondary to epididymoorchitis and pyocele

Abstract

Epididymoorchitis is a relatively common urologic condition involving the scrotum which presents with unilateral pain and swelling. It is typically treated with antibiotics but can progress to complications such as scrotal pyocele. Global testicular infarction is an exceedingly rare but devastating complication of epididymoorchitis. Grey scale and color Doppler ultrasound demonstrate testicular hypovascularity with subsequent hypoechoic changes of the testicular parenchyma. Scrotal MRI shows T2 hyperintense changes through the testicle with nonenhancement of the testicular parenchyma post contrast, consistent with infarction. The cause of global infarction in epididymitis is uncertain but may be due to mixed arterial and venous insufficiency. This case illustrates a 41-year-old male that developed acute left testicular pain. Initial ultrasound showed an enlarged left testicle with hyperemia. The patient's symptoms progressed and a scrotal MRI demonstrated a lack of left testicular enhancement consistent with global infarction, as well as an adjacent pyocele.

Keywords: Epididymitis; Epididymoorchitis; Global infarction; Orchitis; Pyocele.

Fig. 1

Transverse scrotal ultrasound with Doppler shows hyperemia to the left testicle with surrounding inflammatory fluid.

Fig. 2

Repeat transverse scrotal ultrasound performed on hospital day 2 shows formation of left pyocele (yellow asterisk) and reduced Doppler flow to the left testicle. (Color version of figure is available online.)

Fig. 3

Axial T2-weighted image from scrotal MRI performed on hospital day 10 shows a markedly enlarged left testicle with heterogenous hyperintense T2 signal consistent with edema (red asterisk). There is an associated left pyocele (yellow asterisk). (Color version of figure is available online.)

Fig. 4

Axial contrast enhanced T1-weighted image shows global nonenhancement of the left testicle (red asterisk). (Color version of figure is available online.)

Fig. 5

Sagittal contrast enhanced T1-weighted image demonstrating global non-enhancement of the left testicle (red asterisk), suggestive of infarction with sparing of the epididymis (green asterisk). (Color version of figure is available online.)