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Scrotal tuberculosis (TB) is a rare manifestation of extrapulmonary tuberculosis. It includes tuberculous orchitis and epididymitis.
Scrotal TB is rare representing only about 3% of cases of genitourinary tuberculosis 2.
Scrotal TB presents as a painless or slightly painful scrotal mass and so is difficult to differentiate from typical epididymo-orchitis or other conditions such as tumors or infarction 1.
Infection usually affects the epididymis first and then can affect the testis if not treated. It is believed to occur due to a retrograde extension from the prostate and seminal vesicles as well as hematogenous spread 1.
Scrotal tuberculous typically begins in the tail of the epididymis and the ductus deferens.
Tuberculous epididymitis appears as a diffuse heterogeneous predominantly hypoechoic enlarged epididymis or an intrinsic focal nodular hypoechoic lesion. It usually shows increased color Doppler flow, differentiating it from infarction. Bilateral involvement is common, unlike other non-tuberculous infections.
Tuberculous orchitis is usually preceded or associated with epididymitis. Different sonographic patterns have been described 1:
- diffusely enlarged heterogeneously hypoechoic testis
- diffusely enlarged homogeneously hypoechoic testis
- nodular enlarged heterogeneously hypoechoic testis
- multiple small hypoechoic nodules in an enlarged testis (miliary type)
Other associated findings:
- thickened scrotal skin
- scrotal sinus tract
- scrotal hydrocele
- scrotal abscesses
- intrascrotal extratesticular calcification: at epididymis and tunica vaginalis
- evidence of tuberculosis infection elsewhere
Treatment and prognosis
Antituberculous chemotherapy is the mainstay of treatment. Orchiectomy is rarely required for diagnosis or treatment. It may result in infertility 3.
- bacterial epididymo-orchitis
- testicular sarcoidosis
- testicular lymphoma
- primary testicular tumors
- testicular metastasis
- testicular hematoma
- testicular infarction
- a heterogeneous, enlarged epididymis is more commonly seen with tuberculous rather than non-tuberculous epididymitis (which usually appears homogeneous)
- bilateral involvement is more common with tuberculous epididymo-orchitis
- failure of antibiotic therapy for epididymo-orchitis should raise suspicion for a tuberculous etiology
- the presence of pulmonary or extrapulmonary tuberculosis infection elsewhere makes scrotal manifestations more likely to be tuberculous
- associated features which are unusual in non-tuberculous epididymo-orchitis (such as intrascrotal extratesticular scrotal calcifications, scrotal abscess, and sinus tracts) are helpful clues
- 1. Muttarak M, Peh W, Lojanapiwat B, Chaiwun B. Tuberculous Epididymitis and Epididymo-Orchitis: Sonographic Appearances. AJR Am J Roentgenol. 2001;176(6):1459-66. doi:10.2214/ajr.176.6.1761459 - Pubmed
- 2. Das A, Batabyal S, Bhattacharjee S, Sengupta A. A Rare Case of Isolated Testicular Tuberculosis and Review of Literature. J Family Med Prim Care. 2016;5(2):468-70. doi:10.4103/2249-4863.192334 - Pubmed
- 3. Drudi F, Laghi A, Iannicelli E et al. Tubercular Epididymitis and Orchitis: US Patterns. Eur Radiol. 1997;7(7):1076-8. doi:10.1007/s003300050257 - Pubmed
- 4. Nepal P, Ojili V, Songmen S, Kaur N, Olsavsky T, Nagar A. "The Great Masquerader": Sonographic Pictorial Review of Testicular Tuberculosis and Its Mimics. J Clin Imaging Sci. 2019;9:27. doi:10.25259/JCIS-14-2019 - Pubmed