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.
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.
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.
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:
- sexually transmitted
- Neisseria gonorrhoea
- Chlamydia trachomatis
- not sexually transmitted
- Enterococcus spp.
- Staphylococcus spp. (less common)
- Streptococcus spp. (less common)
As with other testicular pathology, ultrasound is the modality of choice. Features consist of 1-2,4-5:
- focal region of altered echogenicity
- usually complex mixed solid/cystic structure
- may be isoechoic to the rest of the testis
- focal region of altered vascularity
- focal avascular region
- surrounding increased vascularity
- evidence of epididymitis (in most cases)
- reactive hydrocoele
- it is important to evaluate for debris or encapsulation to suggest a pyocele
- scrotal skin thickening
- it is important to asses for scrotal wall abscesses
- occasionally intrascrotal gas may be present
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 orchidectomy 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.
Imaging differential considerations include:
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- 2. Berman JM, Beidle TR, Kunberger LE et-al. Sonographic evaluation of acute intrascrotal pathology. AJR Am J Roentgenol. 1996;166 (4): 857-61. AJR Am J Roentgenol (abstract) - Pubmed citation
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