Emphysematous epididymo-orchitis with emphysematous cystitis

Case contributed by Sarah Robertson
Diagnosis almost certain


Right scrotal pain, swelling, erythema, and urinary symptoms. History of type II diabetes mellitus.

Patient Data

Age: 70 years
Gender: Male

Gas locules resulting in 'dirty' posterior acoustic shadowing confined to the right tunica vaginalis and testis without involvement of the soft tissues of the scrotal wall or perineum. Hyperemia of the left testis and epidydmis. Scrotal skin and subcutaneous tissue thickening.

CT confirms the presence of air within the right testicular parenchyma and tunica vaginalis with extension into the right spermatic cord and seminal vesicle. Soft tissue edema and fat stranding of the scrotum without perineal subcutaneous emphysema. Intramural vesical gas. No abnormality of the imaged retroperitoneum.

Case Discussion

Gas confined to the right testis, tunica vaginalis, seminal vesicle, and spermatic cord without involvement of the scrotal wall or perineum is consistent with right emphysematous epididymo-orchitis rather than necrotizing infection of the soft tissues (Fournier gangrene) with testicular involvement, which would be the major differential diagnosis. Hyperemia of the left testis on ultrasound indicates non-emphysematous epididymo-orchitis. Intramural gas in the bladder is in keeping with emphysematous cystitis. 

Blood cultures were positive for Veillonella (gram negative cocci) from a presumed testicular source. The patient was not a surgical candidate and died a few days later.

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