Testicular compartment syndrome: an overview of pathophysiology, etiology, evaluation, and management

Is testicular tissue resection effective in testicular compartment syndrome?

Background

There have been many testicular losses due to testicular compartment syndrome (TCS). Studies are ongoing to lower the pressure within tunica vaginalis during TCS.

Aims

To provide enough space for reperfusion of the testicular tissue and to reduce intratesticular pressure by resecting testicular tissue in the affected testis for treatment of TCS.

Materials and Methods

The study was designed as a prospective randomized animal study. A total of 24 Wistar albino adult rats were randomly divided into three groups. After torsion surgery group 1 underwent detorsion + testicular tissue resection (TTR), while only detorsion was performed in group 2. The control group did not undergo any procedures. At the postoperative 5th day all subjects were sacrificed, and their testes were evaluated in terms of histologic findings, apoptosis, and microangiogenesis. One-way ANOVA and Tukey's test were used for analysis.

Results

According to Johnsen scores, all the groups were statistically different from each other and the damage in group 1 was less than in group 2 (P < 0.05). Factor VIII expressions in surgical groups were significantly higher than in the control group (P < 0.05). However, the surgical groups did not show any significant difference between each other (P > 0.05). Apoptotic cell counts were higher in both surgical groups than in the control group. Also, there was significantly higher apoptotic cell count in group 2 than in group 1 (P < 0.05).

Conclusions

The injury secondary to TCS is lower when TTR is performed. In the cases in which tunica vaginalis graft could not be obtained or in the delayed cases, TTR may be useful.

Testicular Compartment Syndrome After Trauma Managed With a Tunica Vaginalis Flap

Testicular compartment syndrome requires timely diagnosis and intervention but may be challenging. We present a case discussing the presentation and management of testicular compartment syndrome following testicular trauma in an 11-year-old male. The patient presented 24 hours after testicular trauma from a kick with testicular enlargement and sharp pain. Ultrasound showed markedly decreased blood flow and a reactive hydrocele. Testis-sparing intervention included emergent tunica albuginea incision, debridement, and tunica vaginalis flap.

Testicular ischemia secondary to acute epididymitis: A case report

RATIONALE

Rare side effects of acute epididymitis include testicular infarction and ischemia. Distinguishing them from testicular torsion is challenging, both clinically and radiologically. However, only a few such cases have been reported to date.

PATIENT CONCERNS

A 12-year-old child presented with persistent right testicular pain for 3 days. It developed after trauma and was accompanied by gradual swelling and enlargement of the right scrotum, with nausea and vomiting. Scrotal color Doppler ultrasonography demonstrated right epididymitis, right scrotal wall swelling, and right testicular torsion. Routine blood tests revealed leukocyte and neutrophil counts were both above normal.

DIAGNOSIS

Scrotal exploration revealed edema and adhesions in all layers of the scrotal wall. The right testicle was pale. The patient was diagnosed with testicular ischemia secondary to acute epididymitis.

INTERVENTIONS

The patient underwent simultaneous lower spermatic cord sheath dissection and decompression, testicular sheath reversal, and right testicular fixation.

OUTCOMES

Blood flow to the testicles gradually recovered after decompression, as did the color. Postoperatively, the patient's scrotal swelling and pain improved significantly.

LESSONS

Despite the rarity of this condition, it is a potentially serious consequence of epididymitis and should be considered when patients experience sudden scrotal pain.

Comparison of the size of bilateral testis in children with unilateral non-communicating hydrocele and its correlation with age

BACKGROUND

Opinions on the optimal age for surgical management of hydroceles in young boys are not uniform. Scrotal ultrasonography can be used to diagnose hydroceles and measure testicular size. A comparison of bilateral testicular size with hydrocele and the change in trend with age has not been reported. We therefore aimed to analyze the bilateral testicular size of children with unilateral non-communicating hydroceles and examine the correlation between age and testicular volume.

METHODS

Non-communicating hydrocele cases in children were included. Ultrasound results, age, and diagnose time were retrospectively recorded. The bilateral testicular size was compared, and the correlation between age and testicular volume was analyzed.

RESULTS

There were 138 cases of non-communicating hydrocele, ranging in age from 11 to 72 months. The diagnose time ranged from 3 days to 54 months. The volume of the testis on the side of the hydrocele was larger than that on the normal side (P < 0.001). Testicular length was not different bilaterally. Testicular width and height were greater on the hydrocele side than on the normal testicular side (P<0.001). Age was positively correlated with testicular volume on the normal side (P = 0.004) but not on the hydrocele side.

CONCLUSIONS

An important finding was that when the contralateral normal testicular volume increases with age, the testicular volume does not increase on the hydrocele side. This finding confirms the adverse effects of hydrocele on testicular growth and provides a basis for early treatment.

Changes in testicular arterial hemodynamic, gonadotropin levels, and semen parameters among varicocele patients randomized to varicocelectomy or observed in Tamale, Ghana

Objective:

A randomized trial to compared testicular blood flow parameters, gonadal hormones, and semen characteristics among three groups; surgery group ( n = 127); observed group ( n = 114); and healthy controls ( n = 33).

Methods:

The blood flow parameter selected was resistive index (RI) measured using color Doppler ultrasonography. Serum total testosterone, FSH, LH were measured, and semen analysis performed at baseline and repeated 12 months of follow-up. The data was computed using GraphPad Prism (v8.0) at an alpha of 0.05.

Results:

In the observed group, increased +0.0060 in the right (R_RI) and in the left (L_RI) +0.0026 capsular arteries from baseline measurement to 12 months follow-up. Surgery group, reduced –0.079 in the right (R_RI) and −0.0731 in the left (L_RI) capsular arteries ( p < 0.0001). At 12 months, the changes for both left and right RIcap in the surgery group did not reach the values of the controls. In the surgery group, L_RIcap ( r = −0.63; p < 0.0001) and R_RIcap ( r = −0.49; p = 0.004) correlated with total testosterone, FSH ( r = 0.57; p = 0.001 for left; r = 0.52; p = 0.002 for right), and LH ( r = 0.61; p = 0.0002 for left; r = 0.41; p = 0.020 for right). Furthermore, L_RIcap correlated with changes in sperm count ( r = −0.46; p = 0.008) and sperm concentration ( r = −0.35; p = 0.011) in the surgery group.

Conclusion:

Microsurgical sub-inguinal varicocelectomy improves blood supply to the testicular tissues evidenced by reduced resistive index in the surgery group. Resistive index in the left capsular artery can be used to evaluate the success of surgery because it correlates with total testosterone, FSH, LH, and semen quality.

Testicular compartment syndrome: An unexpected diagnosis in a case of testicular pain

This case discusses the presentation of a surprising diagnosis of testicular compartment syndrome in a patient with severe testicular pain and swelling in the Emergency Department.

Testicular infarction as a rare complication of pyogenic epididymoorchitis due to Pseudomonas aeruginosa: A case report and systematic literature review

BACKGROUND

Testicular infarction is a known serious complication associated with epididymitis. It is known to be idiopathic in 70% of cases but the frequency, risk factors, and management are yet to be elucidated. This paper aims to report a case of testicular infarction secondary to pyogenic epididymoorchitis caused by Pseudomonas aeruginosa.

CASE PRESENTATION

A 64-year-old male with a past medical history of benign prostate hypertrophy using intermittent self-catheterization and a recent history of culture-negative pyogenic epididymoorchitis treated with oral cefpodoxime was admitted to our hospital due to a 4-week history of fever, right scrotal pain, and swelling. Scrotal ultrasonography showed a hypoechoic testis without testicular torsion. He was diagnosed with testicular infarction and a scrotal abscess due to Pseudomonas aeruginosa, and was treated with cefepime along with transcutaneous drainage. Despite the antimicrobial treatment, he experienced testicular loss with necrotic tissue. Because little is known about the risk factors, clinical characteristics, management, and prognosis of testicular infarction secondary to epididymitis, we performed a systematic review of the literature.

CONCLUSION

This is a case of testicular necrosis during the treatment of epididymitis with negative urine culture and detection of Pseudomonas aeruginosa in tissue culture. Clinicians should perform frequent blood flow evaluation to the testis for early urologic intervention.

Ultrasound of scrotal and penile emergency: how, why and when

High-resolution ultrasound is the most common imaging technique used to supplement the physical examination of scrotum and penis with great accuracy in assisting the diagnosis of the various pathologies of male genital system, with the highest diagnostic potential in emergency conditions. Technical advancements in real-time high-resolution, color flow Doppler sonography and contrast enhanced ultrasonography (CEUS) have led to an increase in the clinical applications of scrotal and penile sonography. In this pictorial review we focus on common and uncommon male genitalia emergency with special emphasis on the role of ultrasound assessment and its specific findings to improve diagnostic accuracy.

Using shear wave elastography method to evaluate testicular compartment syndrome after testicular torsion

The measurement of compartment pressure is a direct method to objectively evaluate suspected compartment syndrome. However, to evaluate the evolving compartment syndrome, one needs to measure the pressure repeatedly, which may aggravate the damage of tissue. Despite several suggested approaches, an effective, noninvasive and sustainable method to detect testicular compartment syndrome is still lacking. In this context, using the method of shear wave elastography, we assessed the correlation between the intratesticular pressure and the testicular compartment elasticity (Emean) after testicular torsion in rabbits. It was found that a strong correlation between the intratesticular pressure and the Emean in the testicular border area (p < .001) or the central area (p = .001) was present. This result suggests that shear wave elastography is a reliable method to evaluate intratesticular pressure in rabbits, and it may have further potential clinical application in detecting testicular compartment syndrome.

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.

Sutured point-fixation versus Jaboulay fixation for salvaged testicular torsion in children

BACKGROUND

Surgical techniques for fixation of the testis are varied and subject to ongoing debate. Non-sutured techniques may avoid the theoretical morbidities of sutured fixation of the testis yet are criticized for insufficient prophylaxis against future torsion. This study aims to compare outcomes between sutured (point-fixation) versus Jaboulay fixation.

METHODS

Emergency scrotal explorations performed at a tertiary hospital in the state of South Australia between February 2002 and December 2017 were analyzed to identify cases of testicular torsion. Primary outcome measures included future testicular torsions and return to theater episodes following initial testicular fixation. Secondary outcome measures included re-presentations and post-operative complications.

RESULTS

A total of 482 scrotal compartments were explored in 244 boys with acute testicular torsion. Testis fixation was performed using sutured point-fixation in 58.4% and Jaboulay tunica plication in 41.6%. No future testicular torsion occurred regardless of fixation technique. There were no significant differences in returns to theater (0.4% versus 1.2%, p = 0.12), re-presentations (6.9% versus 6.0%, p = 0.83), and post-operative complications (1.7% versus 1.8%, p = 1.0) in testes that previously underwent sutured or Jaboulay fixation, respectively.

CONCLUSION

Jaboulay testicular fixation techniques are comparable with sutured point-fixation techniques in effectiveness and morbidity.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level III.

Testicular ischemia secondary to epididymo-orchitis: A case report

Testicular infarction is a common urological emergency in clinical practice, it is still underreported when it results from other than spermatic cord torsion. It rarely arises from other pathological processes like vasculitis and infectious disease. We report a case of 18-year-old with epididymo-orchitis complicated by testicular ischemia. This case accentuates the need for a high index of suspicion to rule out concomitant testicular ischemia secondary to epididymo-orchitis that might be salvaged in the future with immediate surgical intervention. Testicular infarction is a devastating complication from epididymo-orchitis that is difficult to predict and distinguish from more common presentations of acute scrotum.

Microcirculatory effects of sildenafil in experimental testicular torsion in rats

PURPOSE

Investigate the short-term effect of sildenafil on microcirculation, especially the velocity, the pattern of the flow and the recruitment of the leukocyte in postcapillaries.

METHODS

In male Sprague-Dawley rats, the microcirculatory consequences of 60 min experimental testicular torsion, followed by 240 min of reperfusion, were examined. Using fluorescence intravital microscopy, changes in red blood cell velocity in post-capillary venules and rolling as well as adhesion of leukocytes in the postcapillary venules were examined before the torsion and every hour during the reperfusion period. Sildenafil was given 10 min prior to reperfusion (iv 0.7 mg/kg, n = 6), while control animals received saline vehicle (n = 5).

RESULTS

The characteristic flow motion disappeared in the affected testicular during the torsion. Red blood cell velocity values were dramatically decreased (by > 50%) and both rolling and adhesion of leukocytes increased during the reperfusion phase. Sildenafil treatment resulted in significantly higher red blood cell velocity values during the entire reperfusion period, but exerted only a temporary positive effect on the plost-ischaemic leukocyte-endothelial interactions.

CONCLUSIONS

Intraoperative administration of sildenafil during surgical detorsion may provide marked testicular microperfusion benefits, but failed to influence the overall leukocyte-driven microcirculatory inflammatory reactions.