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Case Report |
1 Department of Radiology, Sonography Section, University of Wisconsin Hospital
and Clinics, Box 3252, E3/311 CSC, 600 Highland Ave., Madison, WI 53792.
2 Department of Urology, University of Wisconsin Hospital and Clinics, Madison,
WI 53792.
Received November 12, 2001;
accepted after revision January 28, 2002.
Address correspondence to M. E. Ledwidge.
Case Report
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Gray-scale and color-flow Doppler sonography of the testicles revealed an enlarged left testicle with heterogeneous echotexture and no flow to the upper pole (Figs. 1A,1B,1C). The lower pole of the left testicle was hyperemic (Fig. 1D) but normal in echotexture, and a small left hydrocele was present. The appearance of the right testicle was unremarkable on gray-scale and color-flow Doppler sonography (Fig. 1E). The right and left epididymides also appeared unremarkable (Fig. 1F). Differential diagnostic considerations included torsion of the left testicle resulting in upper pole infarction and spontaneous detorsion with lower pole hyperemia or severe focal orchitis with subsequent infarction of the upper pole. Because of the possibility of spermatic cord torsion, the decision was made to explore the scrotum.
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At surgery, a bell-clapper anomaly (a narrowed or shortened connection of the testicle to the dorsal scrotal wall that can cause spermatic cord rotation) was identified in both testicles, with no torsion of the spermatic cord evident. The upper pole of the left testicle was dusky with a hemorrhage beneath the tunica albuginea and was subjected to biopsy (Fig. 1F). The lower pole of the left testicle was normal. Because of the apparent viability of the left lower pole, the decision was made not to remove the testicle, and a bilateral orchidopexy was performed. At histopathology, the biopsy specimen showed intratubular necrosis with interstitial hemorrhaging. No evidence of infection was found in the biopsy specimen. The patient did not keep his postoperative appointment and has been lost to follow-up.
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Torsion and detorsion of the testicle that results in hemispheric infarction is a rare condition, and, to our knowledge, the sonographic diagnosis has not been previously reported. Infarction can occur with small degrees of torsion in patients in whom the twist is present for prolonged periods, but higher degrees of rotation (450-540°) may acutely disrupt testicular blood flow [6, 7]. In patients in whom torsion has been chronically present, changes in the testicle can occur that cause the entire testicle to appear echopenic and mottled on grayscale sonography [6].
In this patient, the superior pole of the left testis appeared diffusely hypoechoic and showed no flow on color-flow Doppler sonography. The echogenicity of the inferior pole was normal but appeared to have increased color Doppler flow. Differential diagnosis of this presentation could have included torsion with upper pole hemispheric infarction or severe orchitis with suppuration. In patients with generalized orchitis, the sonographic appearance of the testis is typically that of decreased echogenicity with global hyperemia [8]. Areas of suppuration appear as anechoic or hypoechic areas that typically do not conform to a well-defined vascular territory, as in the case of our patient. In addition, a hypervascular rim may be visible on color-flow Doppler sonography. Because tumors usually appear as mass lesions with some color Doppler flow, it is unlikely that a tumor caused the condition of our patient [9].
In conclusion, there are several causes for acute scrotal pain, and many have overlapping clinical presentations. On sonography, this patient was found to have an abnormal upper testicle with heterogeneous echotexture and no color Doppler flow. At surgery, he was found to have bilateral bell-clapper anomalies, no evidence of infection or tumor, and normal-appearing epididymides. This unusual case of superior hemispheric testicular infarction illustrates the usefulness of sonography to those making clinical decisions because of its capability to rapidly define the anatomy and blood flow within the testicle.
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