AJR 2005; 184:1587-1593
© American Roentgen Ray Society
Radiologic Findings of Segmental Testicular Infarction
Gabriel C. Fernández-Pérez1,
Francisco M. Tardáguila1,
María Velasco1,
Celso Rivas1,
John Dos Santos2,
Javier Cambronero2,
Carmen Trinidad1 and
Pilar San Miguel3
1 Radiology Department, Povisa Medical Center, Salamanca, St. 5 36211, Vigo
(Pontevedra) Spain.
2 Urology Department, Povisa Medical Center, Salamanca, Vigo, Spain.
3 Pathology Department, Povisa Medical Center, Salamanca, Vigo, Spain.
Received April 28, 2004;
accepted after revision August 24, 2004.
Address correspondence to G. C. Fernández-Pérez
(gabrife{at}teleline.es).
Abstract
OBJECTIVE. Our objective was to describe the radiologic findings of
segmental testicular infarction and to establish a proper diagnosis that can
avoid orchiectomy.
CONCLUSION. The presence of a triangular-shaped avascular
intratesticular lesion on sonography or MRI and enhancement of the surrounding
borders on enhanced MR images may suggest a presurgical diagnosis of segmental
testicular infarction and therefore avoid a total orchiectomy in these
patients.
Introduction
Segmental testicular infarction is an infrequent testicular disorder rarely
described in the radiologic literature and usually diagnosed after orchiectomy
[1]. Several etiologic
mechanisms are involved, such as acute epididymoorchitis
[2] and hematologic disorders
such as sickle cell disease or polycythemia
[3], and the disorder has been
associated with vaculitis, such as in hypersensitivity angiitis
[4]. However, no ample series
supports a clear cause because fewer than 40 cases have been reported in the
literature.
This entity affects patients between the second and the fourth decades of
life, although it occasionally has been reported in neonates
[5,
6]. The imaging method of
choice for diagnosis is color Doppler sonography, which shows a flowless area
and normal remaining testicular parenchyma
[7–9].
However, on many occasions, segmental testicular infarction cannot be
distinguished from a tumor with low flow, especially if the tumor is small
[10–16].
Recently, some authors have proposed a role for MRI in the diagnosis of
segmental testicular infarction using contrast sequences
[17].
In this article, we describe the most relevant radiologic findings in 12
cases of segmental testicular infarction studied with sonography and MRI.
Materials and Methods
Patient Evaluation
The study population was selected from a database of 342 patients with
scrotal diseases for whom clinical and imaging data had been obtained between
January 1996 and January 2002. The possibility of segmental testicular
infarction was queried in 12 patients (3.5% of our database; age range,
25–54 years; median, 38 years) who were studied with color Doppler
sonography and MRI, with the latter performed for research purposes during the
first 72 hr after sonography. In five patients, the final diagnosis was
histologically proven by surgery, three by total orchiectomy and two by
partial orchiectomy. In the other seven patients, the inclusion-criteria
diagnosis was established by radiologic suspicion using both imaging methods,
sonography and MRI, when an avascular intratesticular area without mass effect
was associated with negative tumoral markers and followed up monthly for 6
months using sonography. In these patients for whom follow-up was proposed to
confirm the diagnosis, the persistence of negative tumoral markers and the
absence of relevant imaging changes in size and morphology were used to prove
the benign nature of the lesion. In three patients, MRI was also performed to
evaluate possible changes during the first month.
Our institutional review board did not require its approval or a special
informed consent form for our study. The patients were informed according to
the standard information form for MRI. No patient was excluded from this
technique because of contraindications.
Imaging Techniques
Sonography was performed using high-resolution (linear 7-12–MHz
transducer) units (Power Vision, Toshiba; or Logiq 500, GE Healthcare).
Gray-scale, color-flow Doppler, and power Doppler sonography were used to
examine each testis for the presence or absence of intratesticular blood flow.
The power level, threshold, persistence, and wall filter were individually
adjusted to maximize the detection of blood flow. In four patients, MR images
were obtained with a 0.5-T unit (Gyroscan 5T, Philips Medical Systems) using a
circular surface coil. The imaging parameters were as follows: axial and
coronal (or sagittal) unenhanced and enhanced T1-weighted spin-echo images
(TR/TE, 572/20) and T2-weighted turbo spin-echo images (3,257/120). For both
sequences, the section thickness was 6 mm, the intersection gap was 0.6 mm,
the image matrix was 256 x 256, and the field of view was 180–200
mm. Eight patients were studied with a 1.5-T unit (Intera NT, Philips Medial
Systems) with phased-array coil and axial and coronal (or sagittal) sequences
using unenhanced and enhanced T1-weighted turbo spin-echo images (575/11) and
T2-weighted turbo spin-echo images (5,480/140) with 4-mm section thickness and
0.4-mm gap. The image matrix was 256 x 256, and the field of view was
200 mm. Parallel sensitivity-encoded imaging also was used, with a factor of
two, decreasing the acquisition time by half. A bolus of gadolinium chelate
(gadodiamide, Omniscan, Amersham Health), 0.1 mmol per kilogram of body
weight, was injected at 3 mL/sec using a power injector (Spectris, Medrad MR
Injector System). Images were acquired immediately after administration of the
contrast material. All patients were examined in the supine position and with
a folded towel placed between the thighs to avoid motion artifacts from
spontaneous movements of the testes. The entire examination took approximately
15–20 min.
Image Interpretation and Data Analysis
Two radiologists with experience in testicular pathology evaluated the
sonography and MR images by consensus. The retrospective reviewers were aware
of the presence of segmental testicular infarction. The size, location,
morphology, signal intensity, vascularization, and pattern of enhancement
after contrast material administration on MRI were analyzed. The patient's age
and clinical signs and the possible causes of the infarction were also
recorded. Numeric or qualitative variables were reported as median and
percentage.
Results
An acute scrotum was the most frequent clinical presentation, being
observed in eight patients (67%). No cause could be found in more than half
the patients (7/12). However, three patients (25%) presented with an
inflammatory disease (epididymoorchitis), and in two (17%), the affected
testis had recently undergone surgery
(Table 1).
On sonography, all segmental testicular infarctions were solid, and
avascular lesions were in the right testis in seven patients (58%). The median
size was 9 mm, and the range was 3–19 mm. Ten (83%) of the 12 segmental
testicular infarctions were in the upper or middle part of the testis (Fig.
1A,
1B). Segmental testicular
infarctions were usually wedge-shaped—nine cases on sonography (75%) and
10 on MRI (83%)—with the vertex at the testicular mediastinum (Fig.
2A,
2B). However, a round
morphology was also observed in two patients and with both methods (Fig.
3A,
3B,
3C,
3D), the lesion being confused
with an intratesticular tumor. Although those lesions showed absence of
vascularity and negative tumoral markers, patients underwent total orchiectomy
with pathologic results of segmental testicular infarction. MRI on T2-weighted
images showed well-defined borders in all cases with a low (8/12), high
(2/12), or intermediate (2/12) signal intensity in the lesion. In 10 patients,
the lesion was imperceptible on unenhanced T1-weighted images; however, a
central area with high signal intensity representing hemorrhagic foci was seen
in two patients (17%) (Fig. 4A,
4B,
4C,
4D,
4E). On enhanced T1-weighted
images, segmental testicular infarction showed an enhanced rim surrounding the
lesion. This finding was noted in 11 patients (92%), helping to delimit the
lesion (Figs. 4B and
5B). A slight retraction of
the tunica albuginea adjacent to the lesion was detected in four patients,
three of whom had chronic testicular pain. However, in one who presented with
an acute scrotum, the capsular retraction was observed 1 month later during
the first checkup (Fig. 4A,
4B,
4C,
4D,
4E).
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Fig. 1A. —MRI of 42-year-old man with acute scrotal pain in left
testicle. Coronal enhanced T1-weighted turbo spin-echo image (TR/TE, 575/11;
4-mm section thickness) shows segmental testicular infarction in upper
hemisphere of testicle. Lesion is avascular with subtle rim enhancement
(arrowhead).
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Fig. 1B. —MRI of 42-year-old man with acute scrotal pain in left
testicle. Coronal T2-weighted turbo spin-echo image (5,480/140) shows lesion
with low signal intensity and well-defined borders (arrowhead).
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Fig. 2A. —Images of 38-year-old man with previous history of
epididymitis in left testicle, 1 month before. Gray-scale sonogram with linear
7-MHz transducer shows triangular lesion in left testicle (arrowhead)
with vertex pointed to rete testis.
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Fig. 2B. —Images of 38-year-old man with previous history of
epididymitis in left testicle, 1 month before. Color Doppler sonogram shows
hypovascular area with practically no flow in lesion (arrowhead);
only small vessel was seen in outer border. Rest of testicular parenchyma has
normal vasculature. Inset: T1-weighted turbo spin-echo image after
contrast use shows avascular lesion with characteristic triangular shape
(arrowhead). No changes were observed during follow-up.
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Fig. 3A. —31-year-old man with acute pain in left testicle who had
clinical symptoms of epididymoorchitis. Coronal sonogram shows round
intratesticular lesion with nondefined borders in upper pole of left testis.
Lesion was reported as testicular tumor (asterisk). MRI was also
performed.
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Fig. 3B. —31-year-old man with acute pain in left testicle who had
clinical symptoms of epididymoorchitis. Sagittal T2-weighted image (TR/TE,
3,257/120; 6-mm thickness). Arrowhead indicates the round lesion with low
signal intensity.
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Fig. 3C. —31-year-old man with acute pain in left testicle who had
clinical symptoms of epididymoorchitis. Unenhanced (C) and enhanced
(D) T1-weighted images (572/20) show findings similar in morphology but
with borders better defined than on sonography. Enhanced image also defines
avascular lesion with marked rim enhancement of borders. Lesion does not bulge
upper pole of testis, and even this upper hemisphere seems smaller than rest
of testicular parenchyma (arrowheads). Despite this finding and
negative tumoral markers, lesion could not be differentiated from tumor, and
patient underwent orchiectomy. Pathologic result was segmental testicular
infarction.
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Fig. 3D. —31-year-old man with acute pain in left testicle who had
clinical symptoms of epididymoorchitis. Unenhanced (C) and enhanced
(D) T1-weighted images (572/20) show findings similar in morphology but
with borders better defined than on sonography. Enhanced image also defines
avascular lesion with marked rim enhancement of borders. Lesion does not bulge
upper pole of testis, and even this upper hemisphere seems smaller than rest
of testicular parenchyma (arrowheads). Despite this finding and
negative tumoral markers, lesion could not be differentiated from tumor, and
patient underwent orchiectomy. Pathologic result was segmental testicular
infarction.
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Fig. 4A. —38-year-old man with hemorrhagic segmental testicular
infarction in right testicle. Patient was treated for acute scrotum and
suspicion of spermatic cord torsion. MR sagittal T1-weighted unenhanced image
shows high-signal-intensity foci in lesion due to hemorrhage
(arrowhead).
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Fig. 4B. —38-year-old man with hemorrhagic segmental testicular
infarction in right testicle. Patient was treated for acute scrotum and
suspicion of spermatic cord torsion. Sagittal enhanced T1-weighted image shows
avascular lesion, enhancement in periphery, and triangular shape
(arrow).
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Fig. 4C. —38-year-old man with hemorrhagic segmental testicular
infarction in right testicle. Patient was treated for acute scrotum and
suspicion of spermatic cord torsion. Hemorrhagic segmental testicular
infarction has heterogeneous signal intensity on coronal T2-weighted image
(arrow).
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Fig. 4D. —38-year-old man with hemorrhagic segmental testicular
infarction in right testicle. Patient was treated for acute scrotum and
suspicion of spermatic cord torsion. MR coronal T2-weighted images initially
(D) and 1 month later (E) show subtle retraction on tunica
albuginea (arrowheads) in area close to segmental testicular
infarction. This finding was also seen in three other patients who had chronic
evolution of segmental testicular infarction.
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Fig. 4E. —38-year-old man with hemorrhagic segmental testicular
infarction in right testicle. Patient was treated for acute scrotum and
suspicion of spermatic cord torsion. MR coronal T2-weighted images initially
(D) and 1 month later (E) show subtle retraction on tunica
albuginea (arrowheads) in area close to segmental testicular
infarction. This finding was also seen in three other patients who had chronic
evolution of segmental testicular infarction.
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Fig. 5B. —Images of 32-year-old man with small segmental infarction in
lower pole of right testis (arrows). Coronal T1-weighted enhanced
image shows typical enhancement of borders. Center of lesion lacks contrast
enhancement, indicating avascular zone.
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Discussion
Segmental testicular infarction is a partial ischemic process observed on
color Doppler sonography as an area without vascular flow. However, in some
cases, differentiation of segmental testicular infarction from a small
intratesticular tumor, which may have a low flow, is difficult
[7–16].
Diagnosis may be aided by MRI because it easily shows the borders of the
segmental testicular infarction not only on T2-weighted sequences but also on
enhanced images. In sequences after contrast use, one of the most relevant
characteristics of segmental testicular infarction was the presence of a
surrounding markedly enhanced rim, which was seen in more than 90% of the
patients in our series. This feature was also described by Kodama et al.
[17] in one patient and by
Ruibal et al. [18] in three
patients with segmental testicular infarction. Another common finding shown by
both imaging methods was the triangular morphology with the vertex directed
toward the rete testis. In this setting, this morphology is similar to focal
infarctions in other organs, such as spleen or kidney
[19]. Segmental testicular
infarctions with a wedge shape have not been described thoroughly in previous
publications, probably because most cases have been studied by sonography, and
the borders of the lesions are frequently irregular and poorly defined on
sonograms. In some cases, MRI also can show hemorrhagic foci of high signal
intensity on T1-weighted images
[19,
20].
In the evolution of segmental testicular infarction, we did not observe any
significant changes in its morphology, signal intensity, or enhancement.
However, we observed a slight retraction of the tunica albuginea in the area
contacting the lesion, indicating a slight loss of lesion volume due to
hyalinization and fibrosis occurring in the infarcted tissue. These findings
were shown histologically for a surgically removed lesion (Fig.
5A,
5B,
5C,
5D). This feature also has
been reported by Sentilhes et al.
[21] for a patient with
segmental testicular infarction checked after 3 months, for whom orchiectomy
was avoided. In our series, the albuginea retraction was seen in three
patients with chronic pain but also could be observed in the first month of
follow-up for a patient presenting with acute scrotum but for whom the
retraction was not present on the initial study (Fig.
4A,
4B,
4C,
4D,
4E). On the basis of evolution
time and histologic results, the possibility of a repairing process or even a
marked-intensity necrosis with rapid fibrosis of the lesion might explain the
findings.
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Fig. 5A. —Images of 32-year-old man with small segmental infarction in
lower pole of right testis (arrows). Coronal T2-weighted image shows
segmental testicular infarction with low signal intensity and triangular
shape.
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Fig. 5D. —Images of 32-year-old man with small segmental infarction in
lower pole of right testis (arrows). In this patient, segmental
testicular infarction was suspected, but he was one of the first patients
studied and orchiectomy was performed because of our inexperience with this
disorder. A slight tunica albuginea retraction is seen in lesion periphery
(arrowhead).
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The cause was unclear for most of the cases reported, although some were
described as being associated with an inflammatory event (epididymitis or
orchitis), vasculitis, or hematologic disorders (sickle cell disease and
polycythemia)
[1–4].
In our series, the only antecedent that could be shown was epididymoorchitis,
in three patients. Ledwidge et al.
[22] and Dogra
[23] described a patient with
associated bell-clapper anomaly (a deformity or anomaly that leaves the testis
free to swing and rotate within the tunica vaginalis), suggesting that the
cause of segmental infarction was torsion and detorsion of the testis,
producing ischemia in the upper pole of the testis and, secondarily, hyperemia
of the lower pole. In our series, one patient presented with a retractile
testis and repeated episodes of testicular pain, because of which the testis
had to be fixed via orchiopexy. One year later, a routine sonography
examination showed a segmental infarction in the upper pole of the right
testicle. This possible association with the bell-clapper anomaly must be
noted because of the probability that disorders in maturation of the
testicular parenchyma and the testicular vessels may lead to a segmental
infarction, particularly in the testis with a greater possibility of
intrascrotal movement. The testicular artery passes through the inguinal ring
and gives off two branches near the testis (the anterior epididymal artery and
the posterior epididymal artery). After penetrating the tunica albuginea, the
testicular artery, now called the capsular artery, forms branches off each
lobule (centripetal arteries) that run into the septula testis toward the rete
testis. The deferens artery, because it usually anastomoses with the posterior
epididymal artery, provides a second source of blood to the testis. Thus, if
the arterial flow is impaired because of abnormalities in the centripetal
arteries or in the division of the testicular artery or because of an
inconstant anterior epididymal artery, predisposition to a partial infarct
will result, particularly when there are no significant collateral vessels
supplying one or several testicular lobules
(Fig. 6). This point of view
may also explain why, in more than 80% of the patients in our series, the
infarction was in the upper hemisphere of the testis, where vascularization of
the internal testicular artery or superior centripetal vessels could be more
precarious. Moreover, this hypothesis should explain the wedge shape of the
lesion and the clinical presentation of acute scrotum in many patients.
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Fig. 6. —Diagrammatic representation of testicular blood supply. If
anterior epididymal artery (dotted line) is absent or its flow is
impaired (e.g., because of excessive intrascrotal movement of testis, torsion
and detorsion, unobserved interruption of arterial blood flow during
operations performed on spermatic cord within inguinal canal), then capsular
artery will be terminal vessel in upper pole of testis and is not supplied by
collaterals. This possibility may make the patient prone to a focal infarct. a
= artery.
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This study may have had some biases; first, the series was small, without a
comparison with other scrotal abnormalities such as testicular tumor and,
particularly, infarcted tumor, which could show similar findings. However, we
have tried to describe the most important characteristics that we have
observed for segmental testicular infarction, remarking on the usefulness of
MRI. Cases in which the lesion is round must be carefully assessed to avoid
confusion with a nonvascular tumor. This situation, occurring in only two
patients, was the least frequent in our series, but orchiectomy was needed to
totally exclude a hypovascular or infarcted tumor. Another limitation was the
inclusion criterion by which segmental testicular infarction was first
suspected on sonography and then studied with MRI, limiting false-positive or
false-negative results. Also, the final diagnosis of segmental testicular
infarction in those patients who did not undergo surgery may have caused a
bias in patient selection because the method of study was known when our
series of patients was selected. A follow-up period of 6 months was
established in consensus with a urologist. We believe that the possibility
that a slow-growing tumor may have been underestimated is low because we
observed none that not only grew but also changed in morphology and
vascularity. Probably, new studies with more numerous cases will be necessary
to confirm the results of this study, especially in comparison with other
scrotal diseases.
In conclusion, despite the infrequency of segmental testicular infarction,
the radiologist plays a major role in its diagnosis to avoid orchiectomy.
Segmental testicular infarction occurs in the third decade of life, and the
patient usually is referred because of testicular pain and, frequently, acute
scrotum. Color Doppler sonography creates the first diagnostic suspicion by
showing a flowless wedge-shaped lesion. If the borders are not well defined or
the findings are not conclusive, MRI is excellent for establishing the
diagnosis, occasionally showing a hemorrhagic signal and an enhanced halo
delimiting the avascular area. These data, together with the negative tumoral
markers and short follow-up, should allow confidence in the diagnosis, thus
avoiding orchiectomy. Only a few cases that are unclear because of a round
morphology or nonconclusive MRI findings may require surgery and possible
partial orchiectomy.
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Top
Abstract
Introduction
