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We report on an 8-year-old boy with a unilateral testicular mass and bilateral diffusely echogenic testes on sonography. At inguinal exploration torsion of an appendix testis with a reactive phlegmon was found and testis biopsy revealed significant testicular microlithiasis. To our knowledge our case demonstrates a previously undescribed presentation of testicular microlithiasis. The literature is reviewed and this disease entity is discussed.

OBJECTIVE: To review the findings of testicular ultrasonography (US) in patients referred for testicular symptoms including pain, swelling and infertility, and to determine the prevalence of testicular microlithiasis™ and its relevance to the development of testicular cancer. METHODS: Records of 3.026 patients referred for testicular US between 1994 and 1999 were evaluated. The indications for testicular US diagnosis, management and relevant histological details were obtained from medical records. Patients with TM had an annual sonographic follow-up unless they had testicular cancer, in which case follow-up repeat US with clinical reviews was more frequent. RESULTS: TM was found in 54 patients (1.77%; median age, 34 years; range, 12–83 years). The median follow-up was 36 months (range, 12–18 months). Sixteen of these patients had testicular malignancy (30%). The remaining 38 patients had hydrocele and epididymal cysts (14), varicocele (7) epididymitis (2) and small testes (8), with 14 patients having no other pathology. One patient with a small testis developed a seminoma while under surveillance. Another patient with metastatic embryonal-cell carcinoma at initial diagnosis was found to have a seminoma 4 years following chemotherapy. The relative risk of testicular tumors in the presence of TM was 13.2 (confidence interval, 8.3–21.5). CONCLUSION: TM can no longer be regarded simply as a benign condition because of its association with testicular malignancy. In our series, two patients (5.2%) developed interval testicular cancers during follow-up US. There is no convincing evidence to suggest that TM might be premalignant. In rare instances of radiologically indeterminate cases, biopsy of the testis may be necessary.

The patient is a 36-year-old man with a 4-month history of testicular pain unrelieved by antibiotics or antiinflammatory medications. Resuits of scrotal examination were normal. Sonography with an Acuson 128 unit and a 7.5-MHz transducer showed both testes to be of normal size and echogenicity. Diftusely scattered throughout both testes were small homogeneous, nonshadowing, hyperechoic foci (Fig. 1 A). A radiograph of the scrotum made on a General Electric Sonographic 500T mammographic unit with a phototimed exposure of 25 kVp showed diffuse, homogeneous, 1 to2-mm calcifications scattered throughout both testes (Fig. 1B). Because of persistent symptoms, exploratory surgery and biopsies of both testes were performed. On histologic examination, the parenchyma of the testes was normal except for laminated microcalcifications scattered randomly throughout. These calcifications were located in the tubular lumen or beneath the epithelium under a thin layer of connective tissue. The tubules containing the microliths had a variable loss of cellularity (Fig. 1C). One year after biopsy, the patient was asymptomatic and findings on a follow-up sonogram were unchanged. Discussion

Sonographically detected testicular microlithiasis is an uncommon condition, which in recent years has been demonstrated with increased prevalence in patients with testicular tumors. We report a case of a 31-year-old man with left testicular carcinoma and right intratubular germ cell neoplasia diagnosed by biopsy of the right testis at the time of left radical orchiectomy. In this case, preoperative ultrasound revealed right testicular microlithiasis, signaling the presence of intratubular germ cell neoplasia. We propose ultrasound as a noninvasive tool for selecting patients for testicular biopsy.

A 21-year-old man initially presented with a history of bilateral testicular pain and hematospermia. Ultrasound revealed a normal right testis and multiple echogenic foci throughout the left testis consistent with testicular microlithiasis (part A of figure). No focal masses were identified sonographically. Symptoms resolved after treatment for epididymitis. Three years later the patient presented to the emergency department because of increasing back pain. Computerized tomography of the retroperitoneum revealed multiple pulmonary nodules and lymphadenopathy. Ultrasound demonstrated multifocal solid left testicular masses i n addition to testicular microlithiasis (part B of figure). The right testis was sonographically normal. Testicular microlithiasis, and mixed embryonal cell carcinoma and seminoma of the left testis were noted on pathological examination.

Malignant testicular tumor microcalcifications are being reported at an increasing rate. However, whether or not the detection of microcalcifications has any clinical significance has not been clarified. In the present study testicular specimens from 92 patients (43 with malignant and 49 with nonmalignant testicular diseases) were examined postoperatively by mammographic technique. Microcalcifications were identified in 32 of the testicular tumor specimens (74 per pent), more frequently in teratomas (87 per cent) than in seminomas (60 per cent), and in 3 “burned-out” tumors. In contrast, only 8 of the benign testicular specimens showed microcalcifications (16 per cent). The arrangement of microcalcifications as well as the distinct pattern of distribution may further discriminate nonmalignant from malignant entities. Though the rate of detection and allocation of microcalcifications in malignant testicular tumors was a surprising finding, the general use of orchioradiography seems problematic because of the risk of potential damage to the germinal epithelium. In occult carcinoma, however, preoperative orchioradiography may be justified.

Testicular microlithiasis, associated with bilateral cryptorchidism, is studied in 2, 6-year-old children. In case 1 autopsy revealed that 60 per cent of the seminiferous tubules contained completely calcified microliths. Similar mineralized concretions also were found in different areas of the cerebrum and cerebellum. In the testicular biopsy obtained from case 2, 30 per cent of the seminiferous tubules contained microliths showing different degrees of calcification. The study of such calcifications supports the hypothesis that the mineralization process occurs according to the following stages: 1) accumulation of cellular debris in the tubular lumen, 2) deposit of concentric rings of glycoprotein material surrounding the central core and 3) calcification of the glycoprotein lamellar material. The presence of similar concretion in the nervous system as well as the lung in other reported cases suggests that microlithiasis could be a systemic disease.

Light and electron microscopic studies were done on microliths in unilateral undescended testes to determine the origin and structure. The microliths seem to originate from degenerating intratubular cells and consist of a central calcified core surrounded by concentric layers of connective fibers.

Testicular microlithiasis occurring in a postorchiopexy testis is described. The histologic characteristics of this uncommon entity are presented, and its etiology and clinical significance are briefly reviewed.

We present an interesting case of bilateral microlithiasis. Microlithiasis is usually considered a benign condition with no need for follow-up. However, when a patient with testicular microlithiasis has a positive family history of testicular cancer, such patients should be followed up closely to detect the development of testicular cancer.

Testicular microlithiasis was found in a 30-year-old infertile man. The literature is reviewed and the possible influence of testicular microlithiasis on male infertility is discussed.

The sonographic appearance of testicular microlithiasis detected in a patient presenting with torsion is described. A “speckled” pattern of multiple, tiny bright echoes is produced by calcific concretions in the seminiferous tubules and seems to be characteristic of microlithiasis. Although this condition is not treatable, it should be recognized because it is often associated with extratesticular abnormalities and can obscure superimposed testicular disease.

A case report of male infertility associated with testicular microlithiasis is presented. This rare condition has not previously been associated with infertility. A variable maturation arrest was observed in the spermatogenic epithelium. The question of whether the microliths are the cause of the infertility or whether both conditions are the result of some unknown agent must await further elucidation.

Testicular microlithiasis (TM) is a relatively uncommon condition estimated to be found in 5% of the healthy asymptomatic male population and 2% of the symptomatic population. 1.2 Studies have shown an increased prevalence of primary testicular tumors in the presence of TM. 3 However, controversy exists on whether the presence of TM is a risk factor for the development of future testicular tumors or carcinoma in situ (intratesticular germ cell neoplasia). We report a case of bilateral TM with subsequent development of bilateral testicular tumors separated by 4 years.

This pictorial review illustrates the ultrasound appearances of scrotal calcification, distinguishing between intratesticular and extratesticular calcification. Intratesticular calcification may be due to phleboliths, spermatic granulomas or vascular calcification, or it may occur in association with tumours. Extratesticular calcification is more frequently encountered and is usually related to previous inflammatory disease of the epididymis. Testicular microlithiasis, a rare condition characterized by multiple scattered echogenic foci within the testis, is produced by the formation of microliths from degenerating cells in the seminiferous tubules. Testicular microlithiasis has been demonstrated as an incidental finding as well as in association with both benign and malignant tumours of the testis.

Epididymitis is a common presentation of acute testicular pain seen in the emergency department, the differential diagnosis being testicular torsion. The vast majority of young men with epididymitis have an infective aetiology and this settles with antibiotic treatment. The clinical course of a patient who presented with testicular pain is described. At ultrasonography, the patient was found to have the uncommon condition of testicular microlithiasis, a condition that has been linked to malignant disease. Emergency doctors should be aware of the potential consequences of returning scrotal pain consistent with epididymitis to the community on antibiotic treatment alone. All patients with probable epididymitis should have either a scrotal ultrasound or specialist follow up.

Fig. 1-25-year-old man with testicular microlithiasis and subsequent germ cell tumor. A, Longitudinal sonogram of left testis reveals punctate, echogenic, nonshadowing foci representing testicular microlithiasis. Note microliths are concentrated in lower pole. B, Longitudinal sonogram of left testis taken 15 months later shows hypoechoic germ cell tumor (arrows), with cystic region, in lower pole. Microliths are displaced by mass.

The aims of this study were to evaluate the association of testicular microlithiasis with testicular neoplasm, to assess the accuracy of ultrasonography (US) in comparison with histology in detecting microlithiasis, and to identify the prevalent cytohistological features that accompany testicular cancer.Between 2004 and 2005, 14 patients were referred to us for US examination, 13 of whom underwent surgery for testicular cancer. Their age ranged from 19 to 43 years, except for one patient aged 60. US findings and histological examination were compared to assess the accuracy of US in detecting microlithiasis associated with testicular cancer.In two patients (15.3%), microlithiasis had been detected in a previous US examination, and two patients (15.3%) had altered sperm function. At US examination, testicular cancer was associated with microlithiasis in seven out of 13 patients (53.8%) (the distribution pattern of microlithiasis was intranodular in two, perinodular in two and both intra-and perinodular in three), and colour-Doppler US showed perinodular and intranodular vascularity. Histological evaluation identified nine seminomas, two mixed germ-cell tumours, one embryonal carcinoma, one yolk-sac tumour and one benign Sertoli-cell tumour. In nine (69.2%) patients, microlithiasis was confirmed at histologic evaluation, and its distribution was intranodular in two, perinodular in five and both intra-and perinodular in two. Tubular hyalinisation was demonstrated in 12 out of 13 patients (92.3%).Testicular microlithiasis and poor sperm function represent risk factors for testicular cancer: in our study, 30.6% of the patients who developed cancer presented these features. At US examination, testicular microlithiasis is often associated with testicular cancer (53.8%). A high accuracy has been demonstrated for US in detecting microlithiasis (53.8%) compared with histological evaluation (69.2%). At histology, tubular hyalinisation (92.3% of cases) is, with testicular microlithiasis, the most frequent finding in the parenchyma adjacent to testicular cancer.

Corpora amylacea-like bodies are described in the seminiferous tubules of 9 patients with simple cryptorchidism, 3 with cryptorchidism and male pseudohermaphrodism and one with cryptorchidism and prepubertal Klinefelter's syndrome. There were 2 patients with male pseudohermaphrodism and one with prepubertal Klinefelter's syndrome whose testes did not contain intratubular bodies, and such bodies have been described in the scrotal testes by others. It is concluded that the presence of intratubular bodies per se does not have serious implications.

Background: Testicular microliths are calcifications found within the seminiferous tubules. In humans, testicular microlithiasis (TM) has an unknown etiology but may be significantly associated with testicular germ cell tumors. Factors inducing microlith development may also, therefore, act as susceptibility factors for malignant testicular conditions. Studies to identify the mechanisms of microlith development have been hampered by the lack of suitable animal models for TM.\ud Methods: This was an observational study of the testicular phenotype of different mouse models. The mouse models were: cryptorchid mice, mice lacking androgen receptors (ARs) on the Sertoli cells (SCARKO), mice with a ubiquitous loss of androgen ARs (ARKO), hypogonadal (hpg) mice which lack circulating gonadotrophins, and hpg mice crossed with SCARKO (hpg.SCARKO) and ARKO (hpg.ARKO) mice.\ud Results: Microscopic TM was seen in 94% of hpg.ARKO mice (n=16) and the mean number of microliths per testis was 81 +/- 54. Occasional small microliths were seen in 36% (n=11) of hpg testes (mean 2 +/- 0.5 per testis) and 30% (n=10) of hpg.SCARKO testes (mean 8 +/- 6 per testis). No microliths were seen in cryptorchid, ARKO or SCARKO mice. There was no significant effect of FSH or androgen on TM in hpg.ARKO mice.\ud Conclusions: We have identified a mouse model of TM and show that lack of endocrine stimulation is a cause of TM. Importantly, this model will provide a means with which to identify the mechanisms of TM development and the underlying changes in protein and gene expression.