AJR 2001; 176:1459-1466
© American Roentgen Ray Society
Tuberculous Epididymitis and Epididymo-orchitis
Sonographic Appearances
Malai Muttarak1,
Wilfred C. G. Peh2,
Bannakit Lojanapiwat3 and
Benjaporn Chaiwun4
1
Department of Radiology, Chiang Mai University, Chiang Mai, Thailand.
2
Department of Diagnostic Radiology, Singapore General Hospital, Outram Rd.,
169608 Singapore.
3
Department of Surgery, Chiang Mai University, Chiang Mai, Thailand.
4
Department of Pathology, Chiang Mai University, Chiang Mai, Thailand.
Received May 30, 2000;
accepted after revision October 24, 2000.
Presented at the annual meeting of the American Roentgen Ray Society, New
Orleans, May 1999.
Address correspondence to W. C. G. Peh.
Introduction
Before the HIV epidemic, approximately 15% of newly reported cases of
tuberculosis had extrapulmonary involvement. In the years since, reported
cases of extrapulmonary tuberculosis infection have increased, with the
genitourinary tract the most commonly affected site. Extrapulmonary
tuberculosis still presents a diagnostic and therapeutic challenge
[1]. Clinically, tuberculosis
infection of the scrotum often cannot be distinguished from lesions such as
tumor and infarction. Accurate differentiation is, however, important for
proper treatment. High-resolution sonography is currently the best technique
for imaging the scrotum and its contents. This pictorial essay aims to
illustrate the sonographic appearances of tuberculosis epididymitis and
epididymoorchitis.
Clinical Features
Tuberculosis infection of the scrotal contents results from retrograde
extension from the prostate and seminal vesicles as well as from hematogeneous
spread. Infection usually affects the epididymis first, but if the initial
therapy is not appropriate, testicular involvement may follow
[2]. Clinically, patients
present with a painless or slightly painful scrotal mass. The differential
diagnosis of such a scrotal mass includes testicular tumor, acute infection,
infarction, and granulomatous infection
[3,
4]. When clinical findings
mimic those of a tumor, the diagnosis of tuberculosis infection is likely to
be missed because tumors are a more common cause of scrotal mass
[5].
Sonography of Tuberculosis Epididymitis
Tuberculosis epididymitis usually starts in the tail of the epididymis,
either because it has a greater blood supply or because, along with the vas
deferens, it is the first portion to be involved by urinary reflux
[2,
6,
7]. At pathology, the earliest
lesions are seen as discrete or conglomerate yellowish, necrotic areas in the
tail of the epididymis. The disease either regresses and heals, often with
calcifications, or, more commonly, the inflammatory process progresses to
involve the entire epididymis. In the past, tuberculosis epididymitis was more
commonly bilateral, but currently, the disease appears to be more frequently
unilateral [6,
7].
The three gray-scale sonographic appearances of tuberculosis epididymitis
include diffusely enlarged heterogeneously hypoechoic
(Fig. 1), diffusely enlarged
homogeneously hypoechoic, and nodular enlarged heterogeneously hypoechoic
(Fig.
2A,2B,2C,2D)
lesions. Although Kim et al.
[6] and Drudi et al.
[2] noted preferential
involvement of the tail of the epididymis, this sign was not seen in the
series of Chung et al. [7]. Kim
et al. suggested that an enlarged heterogeneous epididymis is reliable in
differentiating tuberculosis from nontuberculosis epididymitis. These findings
were confirmed in the series of Chung et al. The heterogeneity of the
epididymis is thought to be caused by various pathologic stages of the
disease, which include caseation necrosis, the presence of granulomas, and
fibrosis [6,
7].
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Fig. 1. —73-year-old man with tuberculosis epididymitis. Longitudinal
sonogram of right hemiscrotum shows diffusely enlarged heterogeneously
hypoechoic epididymis (E) (solid arrows) adjacent to multiseptated
hydrocele (open arrows). Right testis (RT T) is of normal size and
echogeneity.
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Fig. 2C. —75-year-old man with tuberculosis epididymitis. Photograph of
resected specimen shows marked enlargement of tail of epididymis (straight
arrows). Testis is normal (curved arrow). Gross pathologic
findings correlate well with sonographic appearances.
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Fig. 2D. —75-year-old man with tuberculosis epididymitis.
Photomicrograph of histologic section shows multiple granulomas (large
arrows) surrounded by layers of fibroblasts (arrowheads).
Granulomas consist of chronic inflammatory cells including lymphocytes, plasma
cells, epithelioid histiocytes, and a few multinucleated Langhans' giant cells
(small arrows). (H and E, x100)
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Sonography of Tuberculosis Orchitis
Tuberculosis orchitis usually occurs as a result of contiguous extension
from the epididymis. It is considered to reflect a later stage of the disease
process. Isolated tuberculosis orchitis from hematogenous spread without
epididymal involvement is rare
[7,
8]. Gray-scale sonographic
patterns of the associated tuberculosis orchitis include diffusely enlarged
heterogeneously hypoechoic testis (Fig.
3A,3B),
diffusely enlarged homogeneously hypoechoic testis, and nodular enlarged
heterogeneously hypoechoic testis (Fig.
4A,4B).
Drudi et al. [2] described
multiple small hypoechoic nodules in the enlarged testis as being of the
miliary type and suggested that this sonographic pattern was a feature of
tuberculosis orchitis (Fig.
5A,5B,5C,5D).
This pattern was also found in two of 18 patients in the series of Chung et
al. [7].
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Fig. 3A. —43-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows diffusely enlarged
heterogeneously hypoechoic epididymis (E) (straight arrows) and
testis (T) (curved arrows).
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Fig. 4A. —76-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows nodular enlargement of
epididymis (E) (thick straight arrows), with calcified focus
(thin straight arrow) in right epididymis. Right testis is enlarged
with heterogeneously hypoechoic nodule (N) (curved arrows) within
it.
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Fig. 5B. —43-year-old man with tuberculosis epididymoorchitis (miliary
pattern). Longitudinal sonogram of left hemiscrotum shows multiple small
hypoechoic nodules in diffusely enlarged left testis (LT), with hydrocele
(asterisk) and thickening of left scrotal skin (arrows).
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Fig. 5C. —43-year-old man with tuberculosis epididymoorchitis (miliary
pattern). Photograph of resected specimen shows multiple small nodules in
testis (curved arrows) and enlarged epididymis (straight
arrow).
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Fig. 5D. —43-year-old man with tuberculosis epididymoorchits (miliary
pattern). Photomicrograph of histologic section shows caseating granuloma with
multinucleated Langhans' giant cell (arrow). (H and E,
x400)
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Other Sonographic Features of Scrotal Tuberculosis
Other associated sonographic findings include thickened scrotal skin
(Fig. 5A), hydrocele (Figs.
1,
3B, and
5A), intrascrotal
extratesticular calcification (Figs.
4A,
6A,6B,
and 7), scrotal abscesses
(Figs.
6A,6B
and 7), and scrotal sinus
tract. Thickening of the scrotal skin is best seen when comparison is made
with the unaffected side. Intrascrotal extratesticular sites of calcification
affect the epididymis and the tunica vaginalis testis. In patients presenting
with acute scrotal pain, the finding of reduced or absent vascular perfusion
within the involved testis indicates testicular ischemia, whereas
epididymoorchitis usually results in increased vascular perfusion on color
Doppler sonography (Fig.
8A,8B,8C,8D,8E,8F)
[5,
8].
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Fig. 6A. —58-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of left hemiscrotum shows abscesses (open
arrows) and calcifications (solid arrows) in enlarged
epididymis.
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Fig. 6B. —58-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of left hemiscrotum shows diffusely enlarged
heterogeneously hypoechoic testis (arrows) and septated hydrocele
(asterisk).
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Fig. 7. —60-year-old man with tuberculosis epididymoorchitis.
Longitudinal sonogram of right hemiscrotum shows nodules (curved
arrows) in enlarged right testis, which are heterogeneously hypoechoic,
abscess (open straight arrows) in tunica vaginalis testis, and speck
of calcification (solid thin arrow).
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Fig. 8A. —61-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows right testis
(arrows) is diffusely enlarged. Surrounding right-sided hydrocele can
be seen.
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Fig. 8B. —61-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows nodular enlargement of head
of right epididymis (arrows). Note large multiseptated hydrocele.
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Fig. 8C. —61-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of left hemiscrotum shows nodular enlargement of tail of
left epididymis (E) (arrows). Left testis (LT T) is normal.
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Fig. 8F. —61-year-old man with tuberculosis epididymo-orchitis.
Fine-needle aspiration smear shows multiple acid-fast bacilli
(arrows) among inflammatory cells. (acid-fast bacillus stain,
x1000)
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The sonographic pattern of an enlarged heterogeneous or nodular testis is
nonspecific and may be seen with nontuberculosis infection, inflammation,
tumor (Fig. 9), or infarction.
The addition of color Doppler sonography is helpful in differentiating
infarction from tumor and inflammation. The presence of epididymal enlargement
together with a testicular lesion is suggestive of infection rather than
tumor, because orchitis is almost always caused by epididymitis, whereas tumor
may only partially involve the epididymis in the advanced stage of the disease
[2,
5]. A heterogeneously
hypoechoic pattern of epididymal enlargement favors tuberculosis epididymitis
over nontuberculosis epididymitis, in which the epididymis is more likely to
be homogeneous [6,
7] (Fig.
10A,10B).
Bilateral epididymal involvement is also a useful differentiating feature
(Fig.
11A,11B,11C).
Sonography is helpful for follow-up of treated lesions (Fig.
12A,12B,12C).
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Fig. 9. —17-year-old boy with mixed germ cell tumor. Longitudinal
sonogram of left hemiscrotum shows circumscribed lobulated inhomogeneously
hypoechoic mass (arrows) within left testis. Epididymis and scrotal
skin are normal. In patient with intratesticular mass, normal epididymis, and
normal scrotal skin, inflammatory process is unlikely.
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Fig. 10A. —17-year-old boy with nontuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows enlargement of right
epididymis (large solid arrows) and testis (curved arrows)
with diffuse homogeneously hypoechoic echogenicity. Hydrocele is also present
(asterisk). Scrotal skin is thickened (small solid arrows).
Presence of associated epididymal enlargement and scrotal skin thickening are
features of infection rather than tumor. Enlarged homogeneously hypoechoic
epididymis and testis are more likely to indicate nontuberculosis
epididymo-orchitis than tuberculosis epididymo-orchitis, in which epididymis
is usually heterogeneously hypoechoic.
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Fig. 10B. —17-year-old boy with nontuberculosis epididymo-orchitis.
Longitudinal sonogram of left hemiscrotum shows normal left epididymis (E) and
testis (T). Scrotal skin (arrow-heads) is also normal compared with
right side.
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Fig. 11A. —30-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows nodular heterogeneously
hypoechoic enlargement of head of epididymis (arrows). Small
surrounding hydrocele is present.
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Fig. 11B. —30-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of right hemiscrotum shows diffusely enlarged
heterogeneously hypoechoic right testis (arrows) surrounded by small
hydrocele.
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Fig. 11C. —30-year-old man with tuberculosis epididymo-orchitis.
Longitudinal sonogram of left hemiscrotum shows nodular enlargement of tail of
left epididymis (arrow), small hydrocele (H), and normal left
testis.
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Fig. 12B. —43-year-old man with tuberculosis epididymoorchitis.
Longitudinal sonogram of left hemiscrotum shows diffusely enlarged
heterogeneously hypoechoic left testis (curved arrows) surrounded by
multiseptated hydrocele (straight arrows).
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Fig. 12C. —43-year-old man with tuberculosis epididymoorchitis.
Follow-up longitudinal sonogram obtained 2 years after A and B
shows residual heterogeneous echogeneity of left testis (LT). Epididymis =
E.
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In patients presenting with scrotal swelling, the sonographic detection of
epididymal abnormalities, skin thickening, and hydrocele are suggestive of
infection rather than testicular tumor. Evidence of tuberculosis infection
elsewhere, failure of conventional antibiotic therapy, and scrotal
calcifications, abscess, and sinus tract are helpful clues in aiding the
diagnosis of tuberculosis epididymitis and tuberculosis epididymoorchitis.
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Introduction
Clinical Features
