Torsion of a seminoma in an intrascrotal testis: a case report and review of the literature

Abstract

An intrascrotal testicular torsion with malignant testicular tumour is extremely rare. We report a case of a 26-year-old male who was diagnosed with testicular torsion by magnetic resonance imaging and with testicular seminoma after orchiectomy. Through this case, we found that if the possibility of testicular torsion remains during the diagnosis of acute scrotum cases, additional examination adding to colour Doppler sonography should be performed. Furthermore, we should be aware of the possibility of testicular tumours during the diagnosis and treatment of acute scrotums. If the affected testis is preserved in the treatment of testicular torsion, a postoperative examination by ultrasound and/or tumour markers for the remaining testis is essential to confirm the absence of testicular tumour. IntroductionAlthough various medical devices have been developed in recent years, some testicular torsion is still misdiagnosed. This is due to the technical factors of diagnosis and to the existence of incomplete torsion.1 To confirm a diagnosis of incomplete testicular torsion without surgery is difficult because the symptoms are atypical and the onset is subacute.2 In addition, intrascrotal testicular torsion with testicular tumour is extremely rare, while torsion of underscended testis with testicular tumour have been reported.We describe an unusual case. Our patient presented with incomplete torsion and was histologically diagnosed with testicular seminoma post-surgery. Case reportA 26-year-old male visited our clinic with dull pain in the left lower abdomen and scrotum, lasting 2 hours. He had sexual relations with a sex worker 2 weeks before. His temperature was normal and urinary analysis showed normal levels of white blood cells. An ultrasound revealed swelling of the left epididymis, and colour Doppler sonography (CDS) showed no abnormal signs of blood flow into the left testis. We diagnosed left epididymitis and gave him antibiotics. After 3 days, he returned to our clinic because the pain did not go away. An ultrasound showed multifocal hypo-echoic areas in the left testis (Fig. 1). Blood examination showed abnormal elevation of white blood cells (15200/μL), lactate dehydrogenase (LDH) (888 U/L), and c-reactive protein (CRP) (9.9 mg/dL). Computed tomography (CT) with contrast medium showed normal arterial blood flow around the left testis, but indicated the possibility of hemorrhage in the left testis (Fig. 2a, Fig. 2b). Magnetic resonance imaging (MRI) suggested twisting of the left spermatic cord on the left epididymis and necrosis in the left testis (Fig. 3). We suspected testicular torsion, and an emergency operation was performed.During the surgery, we found the left testis twisted at 90 degrees counterclockwise, and the left testis and epididymis swollen and discolored with a blackened appearance (Fig. 4). We had to perform a simple left orchiectomy because the colour of the testis did not come back to normal after de-twisting it. The gross appearance of a section of the resected left testis reveal...