Testicular abscess is usually a complication of severe epididymo-orchitis and needs to be distinguished from other testicular pathology that may present with similar clinical or imaging features.
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Epidemiology
The majority of patients develop a testicular abscess as a result of untreated or severe epididymo-orchitis. As such the demographics are the same, typically affecting young sexually active adult males 6.
Clinical presentation
In most cases, epididymo-orchitis has been present for some time, and thus typically patients present with testicular pain, often accompanied by fever and swelling, which have lasted a number of days.
In a minority of cases, a testicular abscess can result from bacterial infection an existing hematoma (as a result of testicular trauma) or of a region of infarction (secondary to testicular torsion or mumps) 3.
If the abscess ruptures through the tunica albuginea then a scrotal abscess may develop.
Pathology
Testicular abscesses are most commonly the result of epididymo-orchitis and thus share the same pathogens, and can be broadly divided into those that are sexually transmitted and those that are not 7:
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sexually transmitted
Neisseria gonorrhea
Chlamydia trachomatis
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not sexually transmitted
Enterococcus spp.
coliforms
Staphylococcus spp. (less common)
Streptococcus spp. (less common)
Radiographic features
Ultrasound
As with other testicular pathology, ultrasound is the modality of choice. Features consist of 1,2,4,5:
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focal region of altered echogenicity
usually complex mixed solid/cystic structure
may be isoechoic to the rest of the testis
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focal region of altered vascularity
focal avascular region
surrounding increased vascularity
evidence of epididymitis (in most cases)
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reactive hydrocoele
important to evaluate for debris or encapsulation to suggest a pyocoele
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scrotal skin thickening
important to assess for scrotal wall abscesses
occasionally intrascrotal gas may be present
MRI
The appearance of testicular abscess follows usual pattern of an abscess elsewhere in the body.
T1: hypointense core
T2: hyperintense core surrounded by a hypointense wall with testicular edema
T1C+: wall enhancement with a non-enhancing core
DWI/ADC: diffusion restriction (high signal in DWI and low signal in ADC)
Nuclear medicine
Pertechnetate scintigraphy shows increased perfusion but decreased uptake centrally within the testis at the necrotic core of the abscess.
Treatment and prognosis
Management may include prolonged antibiotics, surgical debridement or even orchiectomy 1,4. If a conservative approach is attempted (i.e medical therapy) then serial ultrasound examinations should be performed to ensure that the abscess does not progress.
If successfully treated, the testis can return to near normal. In some instances, especially if swelling was pronounced, subsequent atrophy may develop.
Differential diagnosis
Imaging differential considerations include:
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