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We report a case of global testicular infarction associated with epididymitis. A 26-year-old man with a history of clean intermittent self-catheterization since he was 1 year old presented to our hospital with left scrotal pain and swelling. He was diagnosed with epididymitis and was prescribed levofloxacin. On the next day, he returned with worsened symptoms of left scrotal pain, swelling, and fever. He was admitted because of his severe symptoms and high C-reactive protein level in the blood test. Antimicrobial therapy with intravenous flomoxef and analgesic treatment with pentazocine and loxoprofen were started but the symptoms did not improve. The color-Doppler ultrasound repeated on the 1st, 4th, and 5th day of admission showed left epididymal hypervascularity but it did not indicate testicular hypovascularity in any examinations. On the 6th day of admission, a contrast-magnetic resonance imaging (MRI) scan revealed no contrast enhancement in the left testis and high orchiectomy was performed. On pathological examination, abscess of the entire epididymis and generalized necrosis of the testes were observed. Inflammatory cell infiltration and thrombus formation were observed in almost all veins of the testis and spermatic cord, and the diagnosis of global testicular infarction associated with epididymitis was made. Global testicular infarction has been reported as a rare complication of epididymitis and should be considered in the case of atypical course of epididymitis.

This report documents a case of asynchronous bilateral testicular infarction. The patient was a 42- year-old man who presented with left testicular pain and swelling. He had a past history of right idiopathic testicular infarction and underwent a right orchiectomy 6 years ago. He also had received treatment for 5 years for suspected polyarteritis nodosa (PAN). The left scrotal pain persisted for a week and left orchiectomy was performed. Pathological evaluations demonstrated a benign testis with testicular hemorrhage and chronic vasculopathy. There was no fibrinoid necrosis of medium-size vessel walls which characterizes PAN. In this report, we review the pathogenesis, risk of contralateral testicular infarction, and management of testicular infarction.

20歳男性.患者は右陰嚢腫大, 陰嚢内痛の悪化で受診となった.所見では, 右精巣, 精巣上体が鶏卵大に腫大し圧痛を認め, WBC, CRPの上昇を認めた.超音波検査では右精巣全体の腫大と内部に不均一な低エコー像を認め, 右精巣上体の腫大と陰嚢壁の肥厚が認められた.一方, CTでは右精巣は腫大し内部濃度は均一であり, MRIでは右精巣は43×38×28mmと腫大し, T1強調でやや高信号, T2強調で不均一な高信号を呈していた.精巣捻転, 精巣腫瘍を疑い, 高位精巣摘除術を施行したところ, 精巣に捻転は認めず, 血栓形成など異常は認めなかった.病理所見では, 精巣・精巣上体は高度に出血壊死しており, 周囲静脈の内腔は拡張し鬱血していた.悪性所見は認められず, 原因不明から特発性の精巣梗塞と診断した.術後経過は良好で4日後に退院となった, We herein report a case of idiopathic testicular infarction. The patient was a 20-year-old man with the chief complaint of right testicular swelling and pain. Ultrasonography and color Doppler sonography demonstrated a hypoechoic lesion without any blood supply. Torsion of the right spermatic cord was most suspected, but we could not exclude the possibility of testicular cancer judging from the findings obtained by computed tomography and magnetic resonance imaging. Surgical exploration did not reveal any torsion of the spermatic cord. Subsequently, right high orchiectomy was performed because of the risk of a testicular cancer. Histopathological examination revealed a hemorrhage and congestion of the testis and epididymis.

症例1:16歳, 男児, 左陰嚢腫大及び発熱を主訴とし, 白血球増多及びCRPの上昇を認めた.造影MRIで左精巣は全く造影されず左精巣梗塞と診断し手術を行った.左精巣は出血性壊死に陥っており摘除, 右精巣固定術も施行した.症例2:12歳, 男児, 左陰嚢腫大及び発熱を主訴とし, 白血球増多及びCRPの上昇を認めた.造影MRIにて左精巣は造影され氏, 左精巣周囲は著明に造影され左精巣梗塞と断定し手術を行った.左精索は鞘膜内で360度回転していた.捻転を解除したが, 精巣の色調は改善せず, 左精巣は摘除, 右精巣は固定術を施行した, The differential diagnosis in acute scrotum, particularly torsion of spermatic cord and epididymitis, is sometimes difficult. An erroneous diagnosis may result in unnecessary and improper treatment. We report two cases of testicular infarction including torsion of spermatic cord, preoperatively diagnosed by enhanced magnetic resonance imaging (MRI). Case 1: A 16-year-old boy presented with a 3-day history of left scrotal swelling and left lower abdominal pain. He had fever and leukocytosis. Antibiotics for 2 days failed to relieve the symptoms. Enhanced MRI showed absence of blood flow in the left testis. Scrotal exploration revealed hemorrhage and necrosis in the left testis. Left orchiectomy and right orchiopexy were performed. Case 2: A 12-year-old boy visited with scrotal swelling and fever 30 hours after an acute onset of left scrotal pain. Enhanced MRI showed absence of blood flow in the left testis. Exploration revealed left necrotic testis with torsion of spermatic cord. Left orchiectomy and right orchiopexy were performed. Our two cases suggested that enhanced MRI, by which the intratesticular blood flow can be evaluated, may be useful for the diagnosis of testicular infarction.

A 6-day-old male was pointed out to have right intrascrotal swelling at birth. Surgical exploration did not reveal torsion of the spermatic cord. The testicle was suspected to have a malignant tumor and then right inguinal orchiectomy was performed. Orchiopexy of the contralateral testicle was not performed due to lack of torsion. Histological examination showed coagulation necrosis of the testicle. Sixty-three cases of testicular infarction in the newborns including our case from Japanese literature were reviewed and discussed.