What is the diagnosis and treatment approach for a male patient of reproductive age with suspected testicular tuberculosis (TB)?

Testicular Tuberculosis: Diagnosis and Treatment

Immediate Diagnostic Approach

For suspected testicular TB, obtain scrotal ultrasound immediately to characterize the lesion, followed by inguinal surgical exploration with excisional biopsy or orchiectomy for definitive diagnosis, as testicular TB is clinically indistinguishable from testicular cancer and requires histopathological confirmation. 1, 2

Key Clinical Presentations

Testicular TB presents in one of three patterns that guide your diagnostic strategy:

• Isolated testicular involvement (extremely rare, only 3% of genital TB cases) typically mimics testicular neoplasm with painless or painful scrotal enlargement in men aged 20-50 years 3, 2
• Epididymal involvement is the most common pattern (78.26% of genital TB cases), often with unilateral presentation affecting left and right sides equally 4
• Extensive genital TB involves multiple sites including epididymis, prostate, seminal vesicles, and vas deferens, presenting with infertility due to ejaculatory duct obstruction 3

Critical Diagnostic Steps

Physical examination must assess: bilateral testicular size and consistency, palpable vas deferens, epididymal enlargement or nodularity, and prostatic abnormalities on digital rectal examination 3, 4

Scrotal ultrasound is the best imaging technique for characterizing testicular lesions, though it cannot reliably distinguish TB from neoplasm 1, 2

Semen analysis reveals characteristic findings when ejaculatory duct obstruction is present: low volume (<1.4 mL), acidic pH (<7.0), and azoospermia or severe oligospermia 3

Hormonal evaluation should include FSH, LH, and testosterone to distinguish obstructive from non-obstructive causes of azoospermia 5

Definitive Diagnosis Requires Tissue

The diagnosis cannot be made by imaging alone. You must proceed with:

• Transinguinal radical orchiectomy when testicular neoplasm cannot be excluded based on clinical and ultrasound findings 1
• Inguinal surgical exploration with excisional biopsy for suspicious masses in the spermatic cord or when fertility preservation is critical 1
• Histopathological examination demonstrating caseating granulomatous inflammation with positive cultures for Mycobacterium tuberculosis 1, 2

USG-guided fine-needle aspiration cytology may confirm diagnosis in select cases where the clinical picture strongly suggests TB and surgical exploration poses excessive risk, though this is not standard practice 3

Rule Out Systemic TB

Because 36.24% of genital TB cases have concurrent TB in other organs, obtain:

• Chest X-ray or CT to exclude pulmonary TB 2, 4
• Urinalysis and urine culture for acid-fast bacilli to detect renal TB (the source of descending genital infection) 3, 4
• Consider abdominal imaging if systemic symptoms or abnormal laboratory findings suggest disseminated disease 4

Treatment Protocol

Anti-TB chemotherapy is the mainstay of treatment following the same regimen used for pulmonary TB: 6 months of standard four-drug therapy (isoniazid, rifampin, pyrazinamide, ethambutol for 2 months, followed by isoniazid and rifampin for 4 months) 3, 5, 2

Surgical Management

• Orchiectomy is performed when testicular neoplasm cannot be excluded or when extensive testicular destruction has occurred 1, 2
• Sperm cryopreservation must be offered before orchiectomy or initiation of anti-TB therapy in men of reproductive age, as fertility may be permanently compromised 5
• Surgical sperm extraction (TESE) should be considered at the time of orchiectomy in azoospermic patients to preserve fertility options 5

Fertility Considerations

Infertility in genital TB results from obstruction at the terminal ejaculatory duct, causing proximal ductal dilatation and preventing seminal vesicle secretions from reaching the ejaculate 3

The fertility prognosis is poor:

• 40.58% of patients with genital TB have sperm quality alterations 4
• Azoospermia may persist despite successful anti-TB treatment when structural obstruction or testicular damage is irreversible 5
• Genetic testing (karyotype and Y-chromosome microdeletion analysis) should be performed in azoospermic patients, as genetic abnormalities may coexist with TB and independently affect fertility 5

Monitoring During Treatment

• Repeat semen analysis at 3 and 6 months after completing anti-TB therapy to assess recovery of spermatogenesis 5
• Serial scrotal ultrasound to document resolution of inflammatory changes 2
• Hormonal reassessment if hypogonadism symptoms develop, as Leydig cell dysfunction may occur 4

Critical Pitfalls to Avoid

Do not delay surgical exploration when testicular neoplasm cannot be excluded, as the median time to diagnosis of genital TB is 26.82 months, during which malignancy may progress if present 4

Do not assume bilateral disease is benign—while TB can be bilateral, testicular cancer with contralateral TB has been reported, requiring careful evaluation of both testes 1

Do not overlook ejaculatory duct obstruction in patients presenting with infertility and low-volume acidic azoospermic semen, as this pattern strongly suggests distal genital tract TB involvement 3

Do not forget to screen sexual partners for TB exposure and consider contact tracing per public health protocols 4