Testicular infarction and spontaneous scrotal rupture secondary to acute epididymo-orchitis

Abstract

Epididymo-orchitis is a common cause of acute unilateral testicular pain. Both infectious or non-infectious causes have been proposed and, rarely, testicular abscess formation and even infarction can occur as a severe complication. We present here a case of acute epididymo-orchitis leading to testicular abscess formation, infarction and spontaneous rupture through the scrotal wall despite appropriate antibiotic treatments. Orchidectomy and partial scrotectomy were performed during surgical exploration for management of the non-viable testis and associated scrotal sinus. Clinical vigilance is important to prevent this complication by close clinical follow up with ultrasonography and even early surgical decompression to prevent testicular loss.

Keywords: ultrasonography; urological surgery.

Figure 1

Grayscale and colour doppler ultrasound of the left testicle showed progression from epididymo-orchitis to testicular abscess formation and rupture. (A–C) At initial emergency department presentation, the left testis was found to be slightly bulky and appears mildly hypervascular, with an associated mild-to-moderate complex hydrocele. (D) There was thickening and vascularity within the left epididymis. The right testis and epididymis appeared normal. The ultrasound scan (USS) diagnosis was moderate left-sided epididymo-orchitis with an associated mild-to-moderate complex hydrocele. (E–G) Two weeks later, repeated USS showed the left testicular morphology was completely deranged. Most of the left testis appeared occupied by a large irregular collection of complex fluid with surrounding oedema and hypervascularity, however reduced flow within the testis itself. The collection appeared to be discharging through a breach in the anterior aspect of the capsule, to the skin. There was marked oedema of the overlying scrotal wall. (H) Left epididymis was grossly enlarged and hyperaemic consistent with epididymitis. The right testis and epididymis were still normal. USS diagnosis was left testicular abscess and sinus, superimposed on acute left epididymitis.

Figure 2

Intraoperative and macroscopic findings. (A–B) Urgent scrotal exploration was performed with resection of the non-viable left testis and overlying discharging scrotal sinus. (C) Necrotic tissue and seminiferous tubules were seen through the defect in the tunica albuginea adherent to the scrotal wall. (D) On the posterolateral view, grossly enlarged spermatic cord and epididymis were seen. (E) Macroscopic longitudinal histological section view showed infarcted testis (*), surrounding fibrotic tissues (arrow) and significant amount of paratesticular abscess draining through the defect in the anterior tunica vaginalis (arrow head).