Presentation
1 week right scrotal swelling and pain.
Patient Data
The right testis is enlarged (21 cc) with a heterogenous echotexture. Multiple small hypoechoic foci in the inferior pole. No internal vascularity detected within the right testis. The right epididymis is hypervascular and enlarged. This is more pronounced at the tail. The right scrotal wall is thickened and hyperemic on color doppler assessment. The right testis is non-tender to transducer probe pressure. The left testis, epididymis and scrotal wall are unremarkable (not shown). Findings are consistent with right testicular infarction from right epididymitis and presumable orchitis.
The patient had a right orchiectomy a day after the ultrasound was performed which demonstrated a necrotic right testis. They were discharged shortly with a plan to be treated with a 7 day course of oral antibiotic.
Case Discussion
This case demonstrates global testicular infarction as a potential consequence of untreated severe epididymitis. Inflammatory edema restricts venous drainage of the testes which exacerbates the increased pressure on the vascular supply eventually restricting arterial inflow. Testicular torsion is unlikely in this case since there is robust hypervascular flow to the ipsilateral epididymis which would not be seen in torsion.
The epidydimal tail was the most engorged and hypervascular part of the epididymis. This is consistent with the pathophysiology of this condition. The patient had a background of poorly controlled diabetes and a UTI prior to onset of symptoms. The bacteria would have translocated in a retrograde fashion from the urethra into the tail of the epididymis.
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