Focal orchitis presenting as bilateral testicular masses

Chlamydia Trachomatis Masquerading as Scrotal Masses in Adolescents

OBJECTIVE

To present a case series of 3 post-pubertal adolescent males with Chlamydia trachomatis presenting as scrotal masses. Scrotal masses are worrisome for malignancy, especially when imaging confirms intratesticular lesions. However, there are benign conditions which may mimic testicular cancer. Some of these conditions may not be readily considered in the pediatric population. This phenomenon is rare in the pediatric population, and this represents only the second report in the literature of this finding.

METHODS

Three cases of adolescent males who presented with a scrotal mass were reviewed. Traditional work up was performed, and results are reviewed.

RESULTS

Median age for these patients was 16 years (range 16-17). All patients underwent scrotal ultrasound confirming intratesticular lesions. Two of the 3 patients denied sexual activity within the past year. Two patients underwent orchiectomy after counseling and shared decision making, with both specimens demonstrating no malignancy. All 3 patients were eventually diagnosed with Chlamydia trachomatis and treated with appropriate antibiotic therapy.

CONCLUSION

Adolescent males who are sexually active can present with Chlamydia trachomatis infection masquerading as a scrotal mass. It is important to consider infectious etiologies in this patient group as it has been documented that many adolescents are hesitant to admit to sexual activity. Thus, routine sexually transmitted infection (STI) screening warrants consideration, and testicular preservation should be sought when it is a viable management option.

Imaging of the scrotum: beyond sonography

The aim of this article is to describe the role of second-level imaging techniques after an initial ultrasonography evaluation in the assessment of scrotal diseases. While ultrasonography remains central as the primary imaging modality for the evaluation of pathologic conditions of the scrotum, the role of magnetic resonance imaging continues to evolve: it can actually be valuable as a problem-solving tool when sonographic findings are equivocal or inconclusive. Magnetic resonance imaging of the scrotum may provide accurate detection and characterization of scrotal diseases, well depicting the precise location of scrotal masses (intratesticular or extratesticular) and reliably characterizing benign conditions simulating neoplastic processes, thus preventing unnecessary radical surgery. Advanced magnetic resonance techniques, most of all diffusion weighted imaging and magnetic resonance spectroscopy, play in the meanwhile a more significant role in evaluating scrotal diseases.

TEACHING POINTS

• Multiparametric ultrasonography usually represents the initial imaging modality for approaching scrotal diseases. • MRI is well established as a problem-solving tool for inconclusive sonographic findings. • Advanced MRI techniques can be successfully applied in scrotal pathology assessment. • MRI is valuable in differentiating benign conditions from neoplastic processes. • CT plays a role in trauma assessment and cancer staging alongside PET/CT.

Perspective in Pediatric Pathology, Chapter 24. Testicular Inflammatory Processes in Pediatric Patients

Acute scrotal pain in children represents a major diagnostic and therapeutic challenge. An important initial differentiation should be made between epididymitis and other processes that cause acute scrotal pain, such as testicular torsion and tumor. Infectious agents disseminating through the blood flow can damage the testis by causing orchitis. On the other hand, infections ascending via spermatic pathways typically lead to epididymitis [ 1 ].

MR imaging of scrotal tumors and pseudotumors

Magnetic resonance (MR) imaging is an important imaging technique in the evaluation of scrotal masses, providing a useful adjunct to ultrasonography (US). Although US is the modality of choice for initial evaluation of scrotal pathologic conditions because of its wide availability, low cost, and high sensitivity for detection of testicular and paratesticular disease processes, US findings may occasionally be inconclusive. MR imaging may provide additional information in these cases, often affecting patient management. This article reviews and illustrates the MR imaging features of solid extratesticular and intratesticular benign and malignant scrotal tumors, as well as nonneoplastic lesions that can mimic neoplasia. Normal scrotal MR anatomic features and optimal MR imaging technique are also presented.

A case of an asymptomatic hypoechoic testicular mass in the setting of contralateral orchitis

BACKGROUND

A 28-year-old heterosexual man presented to an emergency department with a 2-day history of left testicular pain and swelling that began after he started having unprotected sex with a new partner. He also had a 1-day history of fever and chills.

INVESTIGATIONS

Physical examination, urinalysis, complete blood count, polymerase chain reaction testing for gonorrhea and chlamydia, serial scrotal ultrasonography with color Doppler imaging, and measurement of serum tumor marker levels.

DIAGNOSIS

Left orchitis with right testicular mass suspicious for malignancy.

MANAGEMENT

The patient received antibiotic therapy (ceftriaxone and azithromycin), which resulted in resolution of his presenting symptoms. He was discharged from hospital with plans to undergo follow-up evaluation by the urology service. He opted to delay surgical intervention; repeat ultrasonography at 4 weeks revealed signs consistent with treated left-sided orchitis and revealed near-complete resolution of the right-sided lesion. The patient's right-sided mass probably represented subclinical bacterial orchitis, which responded to antibiotic therapy.