From the Guidelines
Focal testicular infarction should be diagnosed using ultrasound with color Doppler imaging, which shows a hypoechoic area with absent blood flow, and managed primarily with conservative measures, including pain control and scrotal support, as recommended by the most recent guidelines 1.
Diagnosis
The diagnosis of focal testicular infarction requires a thorough evaluation, including a physical examination and imaging studies. Ultrasound with color Doppler imaging is the preferred initial imaging modality, as it can demonstrate a hypoechoic area with absent blood flow, indicative of infarction 1.
- The classic imaging appearance is a wedge-shaped avascular focal area on US, although other studies have shown round lesions and color Doppler flow in one series 1.
- If US is equivocal, MRI can be helpful to identify segmental testicular infarction, with findings including a T2 hypointense, avascular lesion with marked rim enhancement 1.
Management
Management of focal testicular infarction is primarily conservative, with a focus on pain control and scrotal support.
- Pain control can be achieved using NSAIDs, such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily for 5-7 days 1.
- Scrotal support and rest are also essential components of conservative management.
- In cases where malignancy cannot be ruled out or symptoms are severe, surgical exploration with possible partial orchiectomy may be necessary, as recommended by the American College of Radiology 1.
Underlying Causes
Patients with focal testicular infarction should be evaluated for underlying causes, including trauma, infection, vasculitis, or hypercoagulable states.
- Blood tests, including complete blood count, coagulation studies, and inflammatory markers, can help identify underlying causes 1.
Follow-up
Follow-up ultrasound is recommended after 4-6 weeks to ensure resolution and exclude developing complications, such as testicular atrophy or recurrent infarction 1.
- Most cases of focal testicular infarction resolve without long-term consequences, although fertility may be affected if the infarction is extensive or bilateral 1.
From the Research
Focal Testicular Infarction
- Focal testicular infarction is a rare complication of prolonged epididymitis and may be misdiagnosed as testicular torsion 2.
- The condition can be easily missed due to a lack of symptom changes, but color Doppler images are helpful in the diagnosis, typically presenting as a decrease in blood flow at the center of the testis with increased flow at the periphery 2, 3.
- The determination of resistance indexes in the Doppler spectrum of intratesticular arteries can show highly increased vascular resistance in respect to the healthy testicle, aiding in diagnosis 3.
Diagnosis and Management
- A high clinical suspicion of testicular ischemia should be maintained in any presentation of testicular pain and swelling, as recognition could lead to early salvage interventions 4.
- Correct diagnosis is difficult but important to avoid unnecessary radical treatment, and making the right diagnosis can prevent an unnecessary radical treatment 5, 6.
- Segmental testicular infarction can be conservatively treated, and surveillance strategy is safe and feasible, with marginal changes in the lesions possible over time 5, 6.
Risk Factors and Associations
- Epididymal tuberculosis should be considered in cases with epididymitis not responding to broad spectrum antibiotics 2.
- Defects in folate metabolism, such as methylenetetrahydrofolate reductase 677C-->T (MTHFR) mutation, may pre-dispose individuals to the development of testicular infarction and infertility 6.