Testicular Atrophy Following Infection: Asymptomatic Presentation
Yes, testicular atrophy following infection can occur asymptomatically, and this represents a significant clinical challenge because asymptomatic or subclinical orchitis may lead to irreversible testicular damage and infertility without the patient ever seeking medical attention.
Evidence for Asymptomatic Infectious Orchitis
The most compelling evidence comes from systematic histopathological studies showing that chronic asymptomatic inflammatory reactions in the testicles have a high prevalence in testicular biopsies from infertile men 1. These mostly focal lymphocytic infiltrates correlate directly with the degree of spermatogenic damage and corresponding clinical and endocrinological parameters of testicular function 1.
Key Clinical Implications:
Asymptomatic testicular infections are underestimated as a primary cause or cofactor of male fertility disorders because noninvasive diagnostic techniques are not yet available to detect them 1
While symptomatic orchitis and epididymo-orchitis with clinical manifestations have well-documented consequences including testicular atrophy and complete loss of fertility, inflammatory reactions that follow an asymptomatic or subclinical course have received little attention 1
The lack of symptoms does not protect against irreversible damage—chronic orchitis can cause irreversible damage to spermatogenesis and corresponding decline of ejaculate quality regardless of symptom presence 1
Documented Cases of Post-Infectious Atrophy
Mumps Orchitis as a Model:
Mumps orchitis provides the clearest evidence for post-infectious testicular atrophy, with documented progression occurring over weeks to months:
Testicular atrophy develops 25-230 days (mean 95.9 days) after initial mumps orchitis diagnosis, demonstrating a delayed progression that may occur after acute symptoms resolve 2
The atrophic testes show characteristic ultrasonographic findings: 23-55% reduction in volume (mean 44.7% smaller) compared to contralateral normal testes, with heterogeneously hypoechoic appearance with multiple hyperechoic islands and decreased vascularity 2
Even with interferon-alpha-2B treatment, testicular atrophy occurred in 38.8% of cases, with an additional 16.6% showing partial (10%) atrophy 3
Trauma-Related Infection and Atrophy:
- Following scrotal trauma, testicular atrophy occurred in 50% of patients at follow-up sonography, with affected testes showing either heterogeneous appearance with reduced flow or homogeneous but reduced volume 4
Clinical Algorithm for Detection
Since asymptomatic testicular infections cannot be reliably detected without invasive testing, clinicians should maintain high suspicion in specific scenarios:
High-Risk Populations Requiring Screening:
Men presenting with infertility should be evaluated for possible chronic asymptomatic orchitis, as systematic histopathological analyses show high prevalence in this population 1
Patients with history of mumps infection (even if orchitis symptoms were mild or absent) should undergo testicular ultrasound 3-6 months post-infection to detect developing atrophy 2
Men with history of scrotal trauma should have follow-up ultrasound evaluation to assess for developing atrophy 4
Ultrasonographic Surveillance:
When asymptomatic testicular atrophy is suspected, Duplex Doppler ultrasound should assess:
- Testicular volume comparison between sides (>20% difference is significant) 2
- Echogenicity patterns: heterogeneously hypoechoic with multiple hyperechoic islands suggests post-inflammatory atrophy 2
- Vascularity assessment: decreased blood flow compared to contralateral testis on color Doppler 2
- Shape changes: oblong rather than elliptical shape suggests atrophy 2
Critical Pitfalls to Avoid
Do not assume absence of symptoms means absence of testicular damage—chronic asymptomatic inflammations are underestimated causes of male infertility 1
Do not rely solely on clinical examination—systematic histopathological analysis is required to detect asymptomatic inflammatory reactions, though this is not practical for routine screening 1
Do not dismiss mild or resolved orchitis symptoms—testicular atrophy can develop months after the acute infection resolves 2
Treatment recommendations for asymptomatic chronic orchitis are largely lacking except for pathogen-specific antibiotics when an infectious agent is identified 1
Broader Context: Asymptomatic STD Infections
The broader literature on sexually transmitted infections reinforces that asymptomatic infections are common and consequential: