"The Great Masquerader": Sonographic Pictorial Review of Testicular Tuberculosis and its Mimics

The Clinical Management of Intrascrotal Extratesticular Masses With Evaluation of Histopathologic Findings

OBJECTIVE

To contribute to the literature by sharing the clinical presentation, surgical approach, postoperative complications management, and follow-up protocols of the patients we operated on due to intrascrotal extratesticular mass.

METHODS

Thirty-two patients admitted due to intrascrotal extratesticular mass were included in the study. Demographic and clinical characteristics of the patients such as age, initial clinical presentation, physical examination, radiological imaging findings, such as scrotal Doppler ultrasonography and magnetic resonance imaging, mass size, and characteristics, surgical treatment procedures, operation notes, and patient follow-up visits were retrospectively examined and evaluated from the patient files.

RESULTS

The median age of the 32 individuals included in the study was 52 (interquartile range: [45.0-60.5]) years. The primary reason for initial presentation was a palpable mass in 25 (78.1%) patients, pain in 13 (40.6%) patients, and scrotal swelling in 8 (25%) patients. The median mass diameter was 4.4 (interquartile range: [3.1-5.7]) cm. Surgical treatment involved inguinal excision in 29 cases (90.6%) and inguinoscrotal excision in 3 cases (9.4%). All patients were treated with testicle-sparing surgery. The most common tumor location, observed in 27 cases (84.3%), was the epididymis. The most frequent histopathological diagnosis was epididymal cyst, identified in 13 patients (40.6%). Pathology results showed that the mass was removed with negative margins in all patients.

CONCLUSION

Testicular-sparing surgery through the inguinal approach is one of the surgical methods that can be preferred for intrascrotal extratesticular masses. This approach can both preserve the testicle and achieve successful surgical results. Studies with larger samples are needed on this subject.

TRIAL REGISTRATION

This study was approved by the Erzurum Medicine Faculty University Local Ethics Committee (approval number: BAEK 2023/08-105).

Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Epididymo-orchitis Presenting as Bilateral Hydrocele in a Young Adult

We present a case of young patient who presented with a progressive scrotal swelling and low-grade fever. An ultrasound of the scrotum revealed multiple small well-defined hypoechoic lesions in both testes with bulky epididymis and bilateral hydrocele. The final diagnosis was confirmed on cytology. The typical imaging findings may help to reach the diagnosis and to plan the further management in such cases.

Tuberculous peritonitis post orchiectomy for testicular tuberculosis; a case report and literature review

Tuberculous peritonitis, though rare, is a serious condition and its diagnosis is challenging due to nonspecific clinical symptoms and imaging findings. Likewise, tuberculous epididymo-orchitis is a clinical dilemma, as it often mimics testicular tumors. We report a case of a 62-year-old patient diagnosed to have TB peritonitis, following tuberculous epididymo-orchitis with review of the imaging features of both entities. A high index of suspicion and careful clinical assessment will help in early diagnosis and treatment of TB peritonitis, preventing potential complications. Moreover, testicular tuberculosis should be considered in the differential diagnosis of scrotal mass.

Testicular torsion as the initial presentation of testicular tuberculosis

Testicular tuberculosis (TB) is a rare disease, and it tends to mimic other testicular diseases which are more common. We highlight the case of a 37-year-old male who presented to the emergency department with testicular torsion. Further investigations revealed evidence of TB.

Is orchiectomy avoidable in testicular tuberculosis mimicking malignancy? A case report

Background

Isolated testicular tuberculosis (TB) is extremely uncommon. It has non-specific presentation; thus, diagnosis is challenging and is often discovered on pathology examination after orchiectomy.

Case presentation

We report herein the case of a 73-year-old male, with no significant medical or family history, who presented with left scrotal swelling, physical examination revealed a left testicular firm mass measuring 3 cm and ultrasound was suggestive of testicular tumor. Left inguinal orchiectomy was performed and the pathologic examination revealed testicular TB. The presentation was typically mimicking a testicular cancer with no evocative evidence of TB; this can lead to a dilemma and highlights the need to consider TB in differential diagnosis of testicular tumor, especially in areas endemic for the disease.

Conclusions

The aim of our presentation is to argue if orchiectomy was avoidable. It also illustrates the probable hematogenous or lymphatic spread of Mtb to the testicle.

Imaging spectrum of common and rare infections affecting the lower genitourinary tract

In this review, we will discuss the imaging findings of common as well as uncommon lower genitourinary tract infections. For both clinicians and radiologists, it is imperative to understand etiopathogenesis, epidemiological information, clinical presentation, imaging findings and management options of such conditions. Knowledge of salient imaging features of these infections is of utmost importance because prompt recognition enables appropriate management.

Imaging Manifestations of Genitourinary Tuberculosis

The genitourinary region is one of the most common sites of extrapulmonary tuberculosis (TB) involvement. The imaging features of genitourinary TB are protean and can mimic other entities, including malignancy, and pose a diagnostic dilemma. Hematogenous seeding and lymphatic spread of mycobacteria from pulmonary, tonsillar, and nodal TB are implicated in the pathogenesis of genitourinary TB. In addition, contiguous extension from the urinary tract and sexual transmission are described as sources of genital TB. Genitourinary TB can be indolent and results in nonspecific signs and symptoms; thus, imaging has a vital role in the working diagnosis for these cases. Classic uroradiologic signs of genitourinary TB are primarily described from the era of intravenous urography and conventional radiography. Now, CT, CT urography, MRI, and US are used in the diagnosis and management. Familiarity with the imaging features of genitourinary TB may help guide the diagnosis and, in turn, lead to timely management. US has a vital role in the evaluation of scrotal and female genital TB. MRI offers superior soft-tissue contrast resolution and excellent depiction of anatomic detail. The various imaging manifestations of genitourinary TB are highlighted. ^©RSNA, 2021.

Male genital tract tuberculosis: A comprehensive review of imaging findings and differential diagnosis

Urogenital tuberculosis is the most common form of extrapulmonary tuberculosis. Genital organ involvement occurs as a continuum of urinary tract tuberculosis and often presents a diagnostic challenge due to the non-specific nature of the symptoms. Delay in diagnosis may lead to complications such as infertility and perineoscrotal sinuses. Imaging plays an important role in raising timely suspicion of tuberculosis. In this article, we describe the imaging findings of male genital tuberculosis and the differential diagnosis. High-resolution ultrasonography (HRUS) is the best modality for assessing the epididymis, testis, scrotum and vas deferens, whereas MRI is optimal for evaluating the prostate, seminal vesicles and ejaculatory ducts. Epididymis is the most common site of genital tuberculosis, and presents as a nodular lesion limited to the tail or as diffuse enlargement. The proximal vas deferens is also frequently involved due to anatomical contiguity and shows diffuse or nodular thickening. Advanced cases may show pyocele formation and scrotal wall sinuses. Testicular involvement is almost always secondary to epididymal tuberculosis and presents as single or multiple nodules, diffuse enlargement, or the 'miliary' pattern. Isolated testicular involvement should raise suspicion of malignancy. Tuberculosis of the prostate is often asymptomatic. The most common imaging manifestations are nodules and the diffuse forms, which may later evolve into abscesses. Fibrosis and calcification occur with healing. Seminal vesicle and ejaculatory duct involvement with fibrosis may cause infertility. Awareness of the imaging findings would enable the radiologist to raise timely suspicion, so that prompt treatment is initiated and complications are prevented.

Drug-Resistant Tuberculosis Presenting as a Testicular Mass: A Case Report

Background

Extrapulmonary drug-resistant tuberculosis is extremely rare and is almost always associated with poor treatment outcomes. This is partly due to the difficulty in confirming the diagnosis.

Case Presentation

A 40-year-old HIV-negative male presented with a painless scrotal mass, low-grade fever, general malaise, night sweats, and no pulmonary symptoms. He was initially treated for malaria with no improvement. His final diagnosis was rifampicin-resistant tuberculosis following Xpert^® MTB/RIF Ultra (Xpert-Ultra) assay performed on a fine needle aspirate of the scrotal mass. Second-line anti-tuberculosis medication was initiated, and the patient is being followed up with directly observed therapy.

Conclusion

With the scale-up of Gene-Xpert technology, this case raises awareness about tuberculosis masquerading as a testicular mass and the possibility of extrapulmonary drug-resistant tuberculosis in high endemic areas.