Testicular infarction is the necrosis of the gland tissues due to circulatory disorders. Symptoms depend on the prevalence of the process. With segmental infarction, a painful dense formation is palpated, accompanied by edema. Extensive testicular infarction has clinical manifestations similar to acute orchoepididymitis, torsion: severe pain syndrome, enlargement of the scrotum on the affected side, hyperemia. Diagnosis is based on the results of ultrasound with Dopplerography, MRI, histological examination. The ambiguity of the data is an indication for diagnostic surgery. Treatment correlates with the depth of ischemia, the inability to normalize blood flow implies orchiectomy.
ICD 10
N50.9 Unspecified male genital disease
General information
Testicular infarction is registered in men of any age, including newborns. Gonad necrosis is most often detected as a result of ischemia, the death of testicular tissues due to vascular catastrophe is rare. In 70%, it is impossible to determine the exact cause, although some authors name potential triggers. According to statistics, adult patients with acute scrotal diseases account for 5-7% of all cases of urgent urological pathology, children – 20%. Specialists in the field of clinical andrology and urology consider early active management tactics for testicular ischemia of any genesis to be a priority, since untimely treatment entails irreversible consequences.
Causes
Testicular infarction potentiates compression of the testis, twisting of its vascular pedicle or blockage of the lumen of the testicular artery. Pathology can be total (involving the entire gonad) or segmented (with necrotizing part of the gland). The scale of the lesion depends on the severity of the provoking factor, the presence of concomitant conditions that lead to changes in the blood system or vessels: vasculitis, periarteritis, sickle cell anemia. Conditions that cause necrosis of part or all of the testicle include:
- Injuries of the scrotum. Damage to the testis with a direct impact is often accompanied by rupture of blood vessels. Compression of the main arteries, veins and lymphatic drainage pathways aggravates edema and extravasation of blood, which initiates oxygen starvation, tissue destruction. In children, trauma to the genital gland during childbirth leads to trophic disorders and necrosis of all testicular structures. Some experts consider asphyxia in childbirth as a provoking factor of testicular infarction in a newborn.
- Urgent states. When the gonad is inverted, the inflow and outflow of blood is disrupted. The predisposing factor is cryptorchidism. Complete torsion potentiates significant venous occlusion, arterial ischemia, which causes testicular infarction. A pinched inguinal hernia affects the patency of the vessels feeding the gonad. Ischemia, which is not associated with emergency surgical conditions, is less common, which is explained by the abundant blood supply to the testes.
- Inflammatory process. Infarction is rarely provoked by orchitis, but with background immunosuppression of any genesis (HIV infection, diabetes, hormone intake), necrosis of tissue structures may occur without timely adequate therapy due to edema that interferes with blood supply. Ischemic inflammation in the testis manifests itself 2-3 days after interventions on the pelvic organs, with damage to the structures responsible for the life support of the testicle structures. It is associated not only with alterations, but with thrombosis, angiospasm.
Predisposing factors include a sharp increase in intra-abdominal pressure as a result of overexertion, masturbation, intense sexual intercourse. Recently, the role of the atherosclerotic process has been proven, when the formation of a cholesterol embolus can cause occlusion of the feeding vessel. The probability of local ischemia is increased by congenital malformations, microangiopathy as a complication of diabetes mellitus, wearing tight underwear.
Pathogenesis
Testicular infarction can be hemorrhagic or ischemic. In the first case, the cause is hemorrhage with a violation of the integrity of the vessels, in the second – the development of acute ischemia due to compression or obturation. Ischemic infarction is caused by any factor that cuts off the blood supply to the genital gland from the testicular artery: torsion, thrombus, immobile large embolus, vascular changes due to severe vasculitis. Complete blockage of blood circulation in 15-20 minutes triggers destructive processes, in 6-12 hours ischemia initiates the death of testicular structures.
Hemorrhagic infarction is usually segmental, associated with embolic events, microcirculation disorders. Pathology is secondary to surgery of inguinal hernias, varicocele. Similar changes occur in orchoepididymitis, when venous circulation is disrupted due to massive inflammatory edema. Conditions associated with increased blood clotting also cause blockage of veins with subsequent necrotizing of tissues. There are observations on the development of hemorrhagic testicular infarction in response to thrombosis of the inferior vena cava.
Classification
Hemorrhagic, ischemic and idiopathic infarction are distinguished. According to histological signs, it is possible to determine the duration of the existence of pathology. The presence of coagulation necrosis, erythrocytes, extravasation of fibrin is considered an indicator of acute infarction. Termination of sperm production in the seminal tubules with thickening of the basement membrane is considered as a subacute process. Chronic infarction is determined by foci of sclerosed seminal tubules with hyalinized interstitial fibrosis. Depending on the scale of the lesion develops:
- Segmental infarction. It is rare, mainly in men aged 20-40 years, in 70-80% it is considered idiopathic. Any localization is possible, but the lesion of the upper segment of the genital gland is more typical. The nature of the pathology is more often established after orchiectomy according to the results of histological examination.
- Total heart attack. It is registered mainly in infants and boys in prepubertal, which is associated with imperfection of the ligamentous apparatus, congenital anomalies of the structure, disproportionate development of the genitals. In adults, a total heart attack is detected against the background of acute orchoepididymitis.
Symptoms
The most common symptom of the focal process is testicular pain, which is nonspecific and indistinguishable from pain in other diseases of the scrotum. A painful motionless (soldered to the surrounding tissues, more often in the upper pole of the gland) formation is palpated, the testicle itself is somewhat swollen, other tissues are not changed. The increase in symptoms usually occurs gradually over 2-3 days, the irradiation of pain can be any.
With a total lesion of the gonad, clinical manifestations are vivid, pain occurs suddenly, due to the underlying pathology – bruising, twisting, pinching. The testicle increases significantly in size, dense, tense. The skin color is variable, initially ischemia leads to a whitish coloration (there is no microcirculation of blood), then a bluish tinge appears, there is an increase in temperature. The severity of the sensations borders on pain shock, tachycardia, pallor, sticky sweat, collapse are typical. Sometimes there is nausea, vomiting, confusion.
Complications
Testicular infarction is a complication of a number of urological conditions, its negative consequences are expressed in the loss of the gonad. In a unilateral process, the functions of sperm production and testosterone production are performed by the second sex gland. With concomitant vascular pathologies or on the background of a bilateral lesion, for example, with underdevelopment of the ligamentous apparatus fixing the testicles to the scrotum, it is impossible to exclude a repetition of the situation. Repeated heart attacks can lead to hypogonadism with lifelong hormone replacement therapy, infertility.
Initially, necrosis is aseptic, but with the addition of secondary microflora, the affected gonad becomes a source of infection. There is a possibility of abscess formation, the risk of developing Fournier gangrene – purulent necrotic fasciitis with high mortality increases. In some men, after orchiectomy, a decrease in sexual function is recorded, which is also associated with psychological aspects. Patients after conservative treatment should be monitored by a urologist due to an increased likelihood of developing cancer within 10-13 years.
Diagnostics
Early diagnosis of acute scrotum conditions is extremely important, since timely initiation of therapy provides prevention of complications. After a conversation with the patient, during which the circumstances of the development of the disease and contributing factors are clarified, the urologist proceeds to a physical examination. The use of modern methods of examination (MRI, duplex scanning of the testicle) in focal infarction avoids organ-bearing surgery. The diagnostic algorithm includes:
- Laboratory tests. In the general blood test, the number of leukocytes is higher than normal, ESR is accelerated, C-reactive protein is detected; indicators tend to increase. For differential diagnosis between focal infarction and malignant neoplasm of the gonad, tests are prescribed for tumor markers: AFP, β-hCG, LDH, which increase in 60% of cases with oncological lesions.
- Visualization techniques. Ultrasound scanning is considered the gold standard for all types of scrotum pain. With a localized infarction, a wedge-shaped hypoechoic lesion with signs of ischemia is located. If the results are ambiguous (hypovascular tumor is suspected), MRI of the genitals is indicated. Duplex scanning allows you to assess the pulsation of the testicular artery, with extensive necrosis it is absent.
- Search operation. If it is impossible to establish the cause of acute scrotum, diagnostic surgical intervention is resorted to: the skin of the scrotum is cut, internal structures (testicle, appendage, appendage suspensions, vascular bundle) are audited. If necessary, perform detorsio (unwinding) when the testicle is inverted, the viability of the tissues is evaluated.
Differential diagnosis is carried out with allergic swelling of the scrotum, purulent-inflammatory diseases: abscess, phlegmon, erysipelas. With a partial gonadal infarction, there is always a suspicion of a tumor process. With orchoepididymitis, in addition to sharp pain in the testicle, there is a pronounced increase in temperature, but hyperthermia can develop a few hours after a heart attack or testicular torsion. The final diagnosis can be established only after a comprehensive examination.
Treatment
The choice of therapy methods is influenced by the pathogenetic factor, the possibility of restoring blood flow, and the age of the patient. The degree of destructive changes correlates with the duration of obstruction of the vessels of the spermatic cord. With ischemia lasting less than 6 hours, a 90-100% probability of a successful outcome remains. After 12-24 hours, tissue death is recorded in 20-50%. After a day, the probability of preserving the testicle is 0-10%, an orchiectomy is required. With a total infarction, the sexual gland is completely removed, with a segmental process, local excision of the altered tissues is possible.
Conservative therapy
In case of extensive testicular infarction, it is not applicable. Management tactics for segmented necrosis remains controversial, but confidence in a local lesion with confirmation from duplex scanning and MRI data leaves the possibility of prescribing medications to improve blood circulation, antispasmodics, blood thinners. A prerequisite is monitoring the state in dynamics. If therapy is unsuccessful, an increase in the focus is resorted to surgical intervention.
Surgical treatment
Urologists consider the condition as urgent, operations are carried out in an emergency. In the localized form, the goal of the intervention is to preserve healthy testicular tissue. Partial orchiectomy is considered the optimal choice for young patients. Nevertheless, most cases of segmental testicular infarction are completed by organ-bearing surgery due to the inability to exclude a malignant lesion.
After the testis is exposed, the doctor evaluates the color of the gland tissues, and intraoperative histological examination is possible in large centers to differentiate between the tumor and focal infarction. During the inversion, unwinding is performed, after the restoration of blood flow, the testicle is fixed to the scrotum (orchipexia). Idiopathic infarction implies total orchiectomy due to the likelihood of the development of a purulent-necrotic process, atrophy with malignancy. In the long-term period, plastic surgery is possible to recreate the normal anatomical size of the scrotum.
In the postoperative period, antibiotics, drugs to improve blood supply, vitamins are prescribed. To prevent hydrocele, it is recommended to wear suspensions, avoid lifting weights. Sexual life can be resumed after 4-6 weeks. The transferred ischemia negatively affects spermatogenesis, even with a favorable course for 36-40 weeks, the full production of sperm and testosterone by the affected gonad remains impaired.
Prognosis and prevention
With timely treatment and treatment, the prognosis for life is favorable. After a unilateral lesion, a state of hypogonadism (androgen deficiency), infertility does not develop. An undiagnosed testicular infarction against the background of twisting of the cord vessels with spontaneous detorsion (unwinding) leads to atrophy of the gland with the risk of malignancy, therefore, it is recommended to remove the testicle even in the absence of pain.
Prevention implies a careful attitude to the organs of the scrotum: wearing protective equipment during traumatic sports, choosing clothes according to the season, timely treatment of chronic urological diseases. Refusal of casual sexual relations prevents infection with STIs, which are often complicated by orchitis. In vascular pathologies, it is important to take medications to improve the rheological properties of blood, the state of the vascular wall. Newborn boys should be examined by a urologist for timely detection of cryptorchidism.