Acute Epididymo-orchitis-Related Global Testicular Infarction: Clinical and Ultrasound Findings With an Emphasis on the Juxta-epididymal String-of-Bead Sign

An Overview of Emphysematous Epididymo-Orchitis: A Systematic Review of Case Reports

Emphysematous epididymo-orchitis (EEO) is a rare but serious condition that involves the presence of gas within the tissues of the testicle and/or the epididymis. It is a medical emergency that can be life-threatening if left untreated. Management of this condition may involve a combination of antibiotics, surgical drainage, and supportive care. In March 2023, A systematic review of case reports was conducted to identify and examine cases of EEO. We used PubMed, ScienceDirect, and Google Scholar for a methodical search. Only seven out of 136 studies met our criteria for this review of case reports. However, this review discusses symptom presentation, imaging findings, complications, and possible management of EEO.

Epididymo-Orchitis Leading to Global Testicular Infarction in a Pediatric Patient - A Case Report

Epididymo-orchitis (EO) is a common urologic condition that rarely requires surgical intervention. Global testicular infarction is an exceedingly uncommon complication of EO and is thought to occur when severe epididymal edema compresses testicular vessels. We present a rare case of global testicular infarction secondary to EO in a 17-year-old boy. Predicting which cases of EO will progress to testicular ischemia is challenging, as no clear risk factors have been identified. Early recognition of testicular compromise requires a high degree of clinical suspicion and may provide the opportunity for testis-sparing intervention.

Do Not Get It Twisted: Common and Uncommon Manifestations of Testicular Torsion

Color flow and spectral Doppler ultrasound are the backbone of scrotal imaging when evaluating acute scrotal pain. Testicular Torsion is one of the most common causes of acute scrotal pain but can be a challenging diagnosis both clinically and sonographically. This article will review the pertinent Doppler ultrasound findings that can help make the diagnosis of both complete and partial torsion. A review of other causes of testicular ischemia will also be included as these pathologies can mimic Testicular Torsion.

A systematic review on the utility of ultrasonography in the diagnosis of testicular torsion in acute scrotum patients

INTRODUCTION

Ultrasound is a valuable tool in establishing the cause of acute scrotum pain. However, its role in testicular torsion (TT) detection remains controversial. This review aims integrate pre-existing data to assess the value of B-mode and colour Doppler ultrasound (CDS) features combined in the detection of TT in acute scrotum pain patients of all ages.

METHODS

A search through electronic databases, grey literature and hand searching using specific search terms was conducted to identify relevant literature. Search results were subjected to a three-step selection process to ensure the inclusion criteria of this review were met. Statistical data pertaining to the accuracy, sensitivity, and specificity of the B-mode, CDS and combined B-mode CDS features were extracted. These results subsequently underwent a narrative analysis.

RESULTS

Five studies met the inclusion criteria. A variety of B-mode features were identified. Most studies showed that reliance on CDS alone can be prone to false-negative results. The combination of B-mode and CDS features were found to increase the overall sensitivity of ultrasound towards TT (up to 100% in 3 studies). All studies recommended correlation with clinical examination findings. Several limitations in methodology of the included studies were noted: small sample populations and lack of information on the experience of ultrasound practitioners. This highlighted the need for a primary study with a larger sample population to validate the findings of this review.

CONCLUSION

The combination of B-mode and CDS ultrasound is a useful and reliable triage tool in the detection of TT, particularly in equivocal or low suspicion cases but its findings should always be adjunct with clinical examination. Nevertheless, it is noted that appropriate service level agreements, pathways, and training are key factors in ensuring effectiveness of the process.

IMPLICATIONS FOR PRACTICE

Dedicated training and appropriate departmental protocol are key in ensuring accurate diagnosis across all levels of practice.

Case report on secondary testicular necrosis due to fulminant epididymitis: ultrasonographic evaluation and diagnosis

BACKGROUND

Scrotal pain is a common complaint in the clinical practice, with many underlying causes. Infectious causes, like epididymitis, are frequently encountered in the work-up of scrotal pain. The presentation of epididymitis is mostly mild, yet major complications can occur.

CASE PRESENTATION

We present a 35-year-old male presenting with scrotal pain and swelling of the testicle. Epididymitis with testicular necrosis was diagnosed using repeated doppler ultrasonography measurements. An orchiectomy was performed which showed a hemorrhagic process with affected spermatic cord. Funiculitis together with epididymal swelling can impede testicular blood flow, with testicular necrosis possibly resulting in orchiectomy. This is the first case that proved funiculitis to co-exist in loss of colour doppler on pathological evaluation.

CONCLUSIONS

In order to reduce major complications, medical therapy should be promptly initiated when there is a suspicion of epididymitis.

Challenges in the diagnosis of testicular infarction in the presence of prolonged epididymitis: Three cases report and literature review

INTRODUCTION

Testicular infarction is a rare complication of prolonged epididymitis and may be misdiagnosed as testicular torsion. In this study, we present three cases of testicular infarction and discuss their clinical characteristics, imaging features and clinical management.

PATIENTS AND METHODS

Three adult males with prolonged epididymitis presented with chronic unilateral testicular pain, tenderness, and palpable swelling, including left varicocele in one case and hydrocele in the other two cases. Patient's symptoms were not relieved after antibiotic therapy. We analyzed the diagnosis, management, and outcome of these three cases of testicular infarction resulting from prolonged epididymitis. This includes the clinical characteristics, features of color doppler ultrasound imaging for diagnosis, and treatment strategy for testicular infarction from prolonged epididymitis.

RESULTS

Complete blood count (CBC) indicated a small leukocytosis (10.6±0.4×109/L; normal arrange 3.5-9.5 WBC×109/L). Color doppler images demonstrated appropriate blood flow to areas of interest at patient's initial visit. At follow up visit several months later, the increased blood flow was detected at the edges of the involved testes with no blood flow to the center. The sizes of the involved testis (27±4 ml) was significantly larger compared to the non affected side (17±2 ml) (p < 0.05). Unilateral simple orchiectomy was performed on the involved testis in all three cases. Grossly, abscess cavities with caseous necrosis were found at the center of the testicle and epididymis in two patients. Histopathologic examination showed chronic inflammation with lymphocytic and macrophage infiltration of the involved testicle in two cases. The third case stained positive for acid fast bacteria. Left varicocele disappeared postoperatively in one patient. No pain, wound infection or other discomfort were noted 12 months after surgery.

COMMENTS

This series revealed that testicular infarction may result from inappropriately treated prolonged epididymitis. Epididymal tuberculosis should be considered in cases with epididymitis not responding to broad spectrum antibiotics. Testicular infarction induced by prolonged epididymitis is easily missed due to a lack of symptom changes. Color doppler images are helpful in the diagnosis. This usually presents as a decrease in blood flow at the center of the testis with the increased flow at the periphery differentiating this from testicular torsion.

Acute epididymo-orchitis: relevance of local classification and partner's follow-up

Introduction

Acute epididymo-orchitis (AEO) is a male urological emergency without an approved clinical classification. We aimed to determine the clinical value of proposed in 2012 local AEO classification system and summarize results of partner's follow-up.

Material and methods

A total of 293 patients with AEO were enrolled into our study. Based on the investigated AEO classification, they were divided into four groups: 118 patients (40.3%) with Stage I AEO; 97 patients (33.1%) with Stage II AEO; 42 patients (14.3%) with Stage IIIA AEO; 36 patients (12.3%) with Stage IIIB AEO.

If after 72 hours of conservative treatment there was no clinical improvement, AEO patients underwent surgery. We analyzed the clinical value of the investigated classification system and results of partner's follow-up.

Results

Only 3 (2.5%) patients with Stage I AEO required surgery. In patients with Stage II AEO, conservative treatment was effective in 79 (81.4%) cases. A total of 27 (64.3%) patients with Stage IIIA and 36 (100%) patients with stage IIIB AEO underwent surgery. Sexually transmitted infections (STIs) were detected in 176 (60.1%) cases among 293 patients with AEO and bacterial infection in 117 (39.9%) cases. We registered a statistically lower incidence rate of trichomoniasis in AEO patients compared to their sole female partners (13.8% vs. 23.3%, p <0.05). Distribution of other STIs in AEO patients and their sole partners was similar.

Conclusions

The investigated classification system enables the determination of a treatment strategy in patients with AEO. Partner's follow-up allows for the clarification of the etiology of disease, complete evaluation of STIs and prevents reinfection in couples.

The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis

PURPOSE

A positive whirlpool sign (WS) is defined as the presence of a spiral-like pattern when the spermatic cord is assessed during ultrasonography (US), using standard, high-resolution ultrasonography (HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion. The objective of this review was to assess the validity and accuracy of this sign by performing a comprehensive systematic literature review and meta-analysis.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive literature search was performed (August, 2017), using the following databases: BMJ Best Practice, Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Selected studies were further assessed for relevance and quality using the Oxford 2010 Critical Appraisal Skills Program (CASP).

RESULTS

Of the studies assessed, a total of 723 participants were included, with a mean of 72.3 (SD 71.9) participants. Of the participants, 226 (31.3%) were diagnosed with testicular torsion (TT). Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity of the WS of 0.73 (95% CI, 0.65-0.79) and 0.99 (95% CI, 0.92-0.99), respectively. Removal of all neonates increased the pooled sensitivity to 0.92 (95% CI, 0.70-0.98) while the pooled specificity remained almost unchanged at 0.99 (95% CI, 0.95-1.00). The estimated summary effect of all studies with sufficient data was 4.34 (95% CI, 1.01-7.67; n = 394; p = 0.001). A large degree of heterogeneity was suggested by an I² statistic of 88.27% (95% CI, 68.60-98.68%). Removal of neonatal subjects increased the estimated summary effect to 5.32 (95% CI, 1.59-9.05; n = 375; p = 0.001).

CONCLUSION

The WS, when correctly diagnosed, may be viewed as a very definitive sign for TT in the pediatric and adult populations. However, its role in neonates is limited.