Radiological Case: Polyorchidism With Intermittent Testicular Torsion

Dana Sylvestre; Adam S. Brown, MD; Deborah Conway, MD

Disclosures

Appl Radiol. 2018;47(11):42-43. 

In This Article

Discussion

This case reveals a rare and potentially first presentation of polyorchidism with subacute/chronic testicular torsion of the left lateral testicle in a male older than 50 years of age. The left and right testicles were normal in echogenicity on US with no apparent mass, cyst, or suspicious calcification. The testicles had normal vascular perfusion on color Doppler US with the additional left lateral testicle demonstrating an absence of vascular flow, leading to the diagnosis of polyorchidism with subacute/chronic torsion.

Polyorchidism is rare, with approximately 140 histologically confirmed cases in the literature.[1] The most common presentation is triorchidism with intrascrotal left-sided predominance.[1] Triorchidism originates from abnormal division of the genital ridge.[1,2] The median age of diagnosis is 17 yo.[1] The supernumerary testis is typically identified subsequent to symptomatic presentation of inguinal hernia, maldescended testis, testicular torsion, hydrocele, or varicocele.[1,3] The differential diagnosis includes hydrocele, spermatocele, varicocele, Morgagnian cyst, and testicular neoplasm.[1]

US and MR can be used to support the diagnosis of polyorchidism.[1,4] In a meta-analysis, US identified polyorchidism in 81% of confirmed cases.[1] In the asymptomatic patient, the supernumerary testis echotexture, MR signal intensity, and vascular flow are similar to normal testes.[3,5] MR can be used for confirmation if the US is equivocal.[3,4,5] Polyorchidism can be managed conservatively with serial US if there is no evidence of malignancy.[5]

Testicular torsion is the result of spermatic cord twisting causing decreased perfusion to the testicle.[6] Patients with torsion commonly have the anatomic variant of the tunica vaginalis joining high on the spermatic cord.[6] Testicular torsion can be classified as acute or intermittent. Acute testicular torsion presents with severe scrotal pain, and it is a surgical emergency due to the risk of rapid testicular necrosis.[7] Intermittent testicular torsion presents with recurrent scrotal pain of short duration that resolves spontaneously.[8] Both acute and intermittent testicular torsion are less commonly diagnosed in adults.[9] Scrotal swelling can be present on examination.[8,9] Intermittent testicular torsion can be managed conservatively or with orchidopexy. Orchidopexy is often recommended to prevent testicular necrosis and relieve recurrent testicular pain.[9]

Imaging plays a key role in the diagnosis of torsion. MR T2-hypointensity indicates testicular torsion and hemorrhagic necrosis.[2,10] While the US echogenicity may initially be unremarkable, necrosis later develops and is indicated by a heterogenous and hypoechoic appearance.[7] Color Doppler US is frequently used for to evaluate acute scrotum, as it demonstrates reduced or absent perfusion of the affected testicle.[2,6,7] However, color Doppler US does not always demonstrate compromised vascular flow in intermittent testicular torsion.[8,9]

processing....