AUCTORES
Review Article | DOI: https://doi.org/10.31579/2690-1919/325
North Manchester General Hospital, Department of Urology, Manchester, United Kingdom,
*Corresponding Author: Anthony Kodzo-Grey Venyo, North Manchester General Hospital, Department of Urology, Manchester, United Kingdom,
Citation: Anthony Kodzo-Grey Venyo, (2023), Tuberculosis of the Testis, Epididymis, Scrotum and Scrotal Contents and Tuberculosis of the Penis and Urethra: A Review and Update, J Clinical Research and Reports, 13(5); DOI:10.31579/2690-1919/325
Copyright: © 2023, Anthony Kodzo-Grey Venyo. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 06 June 2023 | Accepted: 12 June 2023 | Published: 22 June 2023
Keywords: tuberculosis; testis; epididymis; scrotum; penis; urethra; biopsy; histopathology; langhan’s giant cell; caseating granuloma; chemotherapy; pulmonary; recurrence; follow-up. high index of suspicion; rare
Cases of tuberculosis of the testis, epididymis, scrotum and or the penis including the urethra are very rare even though pulmonary tuberculosis is common globally. In view of the fact that tuberculosis of the scrotum and scrotal contents and penis is rare, it would be envisaged that majority of clinicians would not have encountered a case of this infection during their training and professional practices. Tuberculosis which has afflicted either the scrotum, testis, epididymis and penis does manifest with non-specific symptoms that simulate symptoms of more common conditions of the scrotum, scrotal contents and penis and hence a high index of suspicion is required in order to establish a prompt correct diagnosis in order to initiate the correct treatment. Tuberculosis of the testis and tuberculosis of the scrotal contents as well as the penis usually manifests as is as painful or painless testicular swelling with or without scrotal ulceration or discharging sinus. Infertility may occur. Epididymal involvement is usually seen in testicular TB. In most cases, genital TB is associated with TB involvement of kidneys or lower urinary tract. Ultrasound (USG) and USG-guided fine needle aspiration cytology of testicular swelling confirm the diagnosis. Anti-TB chemotherapy is the mainstay of treatment to ensure the complete resolution of the lesion. However, in very few cases, orchidectomy is required for both diagnosis and treatment. Tuberculosis of the scrotum would tend to present as a nodule, ulceration, mass or bleeding or rash on the scrotum. Tuberculosis of the penis would tend to manifest as a nodule, ulceration, a mass or masses on the penis, a urethral fistula or voiding problems. Tuberculosis of the scrotal contents, scrotum or penis may occur alone or there may be a history of contemporaneous pulmonary tuberculosis or tuberculosis elsewhere in the body or there may be a history of an antecedent tuberculosis elsewhere in the body which had been treated before. Isolation and culture of M. tuberculosis, fine needle aspiration cytology (FNAC) and polymerase chain reaction (PCR) may provide an accurate diagnosis of tuberculosis of the scrotum and scrotal contents as well as the penis even though in some cases histology may be the only confirmatory diagnostic modality. Anti-TB chemotherapy is the mainstay of treatment, however, in few cases, orchidectomy is required for both diagnosis and treatment of tuberculosis of the testis and epididymis. Also, on rare occasions when tuberculosis of the penis is misdiagnosed initially as possibly malignancy of the penis, partial amputation of the penis may be undertaken before the diagnosis of tuberculosis of penis is finally confirmed. Nevertheless, if a high index of suspicion for the possible diagnosis of tuberculosis of the scrotum and scrotal contents is maintained then early biopsy of the scrotal and intra-scrotal lesion or penile lesion for pathology examination would help establish the diagnosis of tuberculosis so that mutilating surgery would be avoided. The association between infertility and testicular and epididymis mass should alert the clinician to have a high index of suspicion for tuberculosis. Diagnosis of tuberculosis of the scrotum, testis, epididymis, and or penis can be confirmed by the histopathology examination finding of caseating Granuloma with multi-nucleated Langhan’s giant cell upon pathology examination of biopsy specimen of the lesion.
Conclusions:
It has been iterated that testicular tuberculosis (TB) is an uncommon rare form of genitourinary TB and that testicular TB usually does tend to manifests as painful or painless testicular swelling with or without scrotal ulceration or discharging sinus. [1] The ensuing statements had also been made about cases of tuberculosis (TB) of the testis. [1]
Considering the fact that Tuberculosis (TB) of the testis and epididymis does tend to simulate other more common lesions of the testis and epididymis and the fact that TB of the testis and epididymis is not common, it would be envisaged that a number of clinicians may not be familiar with the manifestations of the lesion and hence there could be delay in the diagnosis of the lesion. A high-index of suspicion is required in order to establish a quick diagnosis of TB of the testis and epididymis. Additionally, TB of the scrotum and penis is very rare and hence majority of clinicians would not have encountered a case of TB of the scrotum and penis during their training as well as their clinical practices and they may not be familiar with the manifestations of TB of the scrotal contents and penis. The ensuing review and update of the literature on TB of testis and epididymis and TB of the scrotum has been divided into two parts: (A) Overview which has discussed general aspects of TB and TB of the testis and epididymis, penis and scrotum and (B) Miscellaneous Narrations Related to Some Case Reports, Case Series and Studies Related to TB of the testis and epididymis with few discussions related to TB of the scrotum and penis.
Aims
To review and update the literature on Tuberculosis of the testis, epididymis, scrotum, penis, and urethra.
Internet data bases were searched including: Google; Google Scholar; PUBMED and Yahoo. The search words that were used included Tuberculosis of the testis, tuberculosis of epididymis, tuberculosis of the scrotum, tuberculosis of the penis, and tuberculosis of the urethra. Sixty-five (65) references were identified which were used to write the article that was divided into two parts: (A) Overview which has discussed various general as aspects of tuberculosis and Tuberculosis of the testis, epididymis, scrotum, penis, and urethra, and (B) Miscellaneous Narrations From Some Case Reports, Case Series and Studies related to Tuberculosis of the testis, epididymis, scrotum, penis, and urethra.
[A} Overview
Definition / general statements [2]
Gross description [2]
Microscopic (histologic) description [2]
Differential diagnosis [2]
Some of the conditions that need to be considered as differential diagnoses to be excluded from tuberculosis of the testis and epididymis include the following: [2]
Laboratory tests
Haematology blood tests.
Routine haematology blood tests including full blood count INR and coagulation screen tend to be undertaken in the initial assessment of patients who manifest with non-specific symptoms related to the penis, testis, epididymis and scrotum. The results may be normal but the white cell count and lymphocyte count levels would tend to be raised but these results would tend not to be specific for the establishment of a specific diagnosis but in the scenario of anaemia, the anaemia would be investigated and treated appropriately to improve upon the general health the patient.
Biochemistry blood tests.
Routine biochemistry blood tests including: CRP, serum urea and electrolytes, liver function tests, bone profile, and random blood glucose tests tend to be undertaken in all cases of tuberculosis of the penis, scrotum, and intra-scrotal contents as part of the general assessment of all patients but generally the results tend to be non-specific and non-diagnostic of tuberculosis of the penis and intra-scrotal contents; nevertheless, if there is evidence of an abnormality in the results of any of the aforementioned tests, it would be investigated and treated appropriately to improve upon the general health of the patient.
Radiology imaging
Chest Radiograph
Majority of cases of tuberculosis tend to afflict the lungs and in cases of tuberculosis of the penis and intra-scrotal contents that are contemporaneous with pulmonary tuberculosis or disseminated tuberculosis, chest radiograph would demonstrate radiology image features of tuberculosis pneumonitis that should alert the clinician to be aware of the possibility of tuberculosis of the penis or scrotal contents.
Ultrasound scan
Ultrasound scan of the scrotum and scrotal contents and the penis would tend to demonstrate features of various types of hypoechoic lesions as well as at times calcification(s) within the testis or and extra-testicular areas of the scrotum, and the calcifications as well as evidence of pulmonary radiograph features of contemporaneous tuberculosis should alert the clinician to suspect the possibility of tuberculosis of the penis, scrotum, or scrotal contests so that biopsy of the lesion can be taken for histopathology examination confirmation of tuberculosis can be confirmed so as to enable commencement of anti-tuberculosis combination therapy and to avoid the undertaking of mutilating excision surgery in many cases.
Computed tomography scan
Computed Tomography (CT scan) of the testes, penis, and scrotal contents would demonstrate various types of hypo-dense areas that could be targeted for biopsy for histopathology examination that would confirm the diagnosis of tuberculosis which would enable commencement of anti-tuberculosis treatment as well as avoidance of the undertaking of mutilating excision surgery including orchidectomy for testicular tumour.
Magnetic Resonance Imaging Scan
Magnetic Resonance Imaging (MRI) CT scan of the testes, penis, and scrotal contents would demonstrate various types of hypo-dense areas that could be targeted for biopsy for histopathology examination that would confirm the diagnosis of tuberculosis which would enable commencement of anti-tuberculosis treatment as well as avoidance of the undertaking of mutilating excision surgery including orchidectomy for testicular tumour.
Diagnosis
Treatment
Outcome
[B] Miscellaneous Narrations and Discussions From Some Case Reports, Case Series, and Studies Related to Tuberculosis of the Testis and Epididymis As Well As Some Cases Of The Scrotum And Penis.
Scrotal tuberculosis
El-Keky et al. [5] iterated that Scrotal tuberculosis (TB) is a rare presentation of extra-pulmonary tuberculosis and that intra-scrotal tuberculosis includes tuberculous orchitis and epididymitis. It has also been stated that scrotal tuberculosis is uncommon and it does represent only about 3% of cases of genitourinary tuberculosis. [5] [6] The ensuing summations had been made about scrotal tuberculosis:
With regard to tuberculous orchitis, it had been stated that tuberculous orchitis is usually preceded or associated with epididymitis and that different ultrasound scan patterns of tuberculous orchitis had been described as follows [5] [7]:
Other associated findings in tuberculous orchitis had been summated as follows: [5]:
With regard to treatment and prognosis of tuberculous orchitis, the treatment has tended to entail the following:
Some of the differential diagnoses of tuberculous orchitis had been stated to include the ensuing clinical entities:
Salient points related to tuberculous epidydimo-orchitis had been summated by el-faky et al. [5] as follows:
Das et al. [1] stated the following:
Das et al. [1] reported a 20-year-old man who had presented with a painful, left-sided testicular swelling without any discharging sinus or scrotal ulceration over the preceding 2 months. He did not have any history of any respiratory symptom, fever, anorexia, and significant weight loss. He was a non-smoker and non-alcoholic. His clinical examination was generally normal, except for the finding of multiple, matted, nontender, firm enlarged inguinal lymph nodes on the left side. His pulse rate was documented to be 80 beats/minute, regular, respiratory rate, 20 breaths/minute, temperature, 97°F, and his blood pressure was 120/80 mmHg. His systemic examination did not demonstrate any abnormality. His right scrotum was normal; on the other hand, his left sided testicular swelling that measured 3 cm × 2.5 cm in size which was noted to be gradually increasing. The testicular swelling was tender, hard, elliptical in shape, and not fixed with the overlying scrotal skin, and the clinician was able to go above the mass. There was no discharging sinus or scrotal ulceration found. The results of his routine haematology and biochemistry blood tests with the inclusion of his fasting blood glucose were normal. Blood for anti-HIV types 1 and 2 antibodies was documented to be nonreactive. His chest radiograph on the posteroanterior view was noted to be normal. Mantoux test (5 TU) was undertaken which was reported to be positive (16 mm induration after 72 h). He underwent ultrasound scan (USG) of his testes which demonstrated that his left testis was enlarged and it had measured 4.8 cm × 2.6 cm. Furthermore, the ultrasound scan demonstrated one 3.2 cm × 2.4 cm × 2.7 cm sized hetero-echoic space occupying lesion with hypoechoic components and small cystic areas which were visualized within the lower pole of his left testis [See figure 1]. The testicular margin was found to appear ill-defined within the lower pole. Upon Doppler ultrasound scanning, increased blood flow was found within and periphery of the lesion. There was no evidence of hydrocele. His left epididymis, spermatic cord, and scrotal skin were noted to be normal. His right testis was found to be normal. Multiple, enlarged lymph nodes were observed within his left inguinal region upon his ultrasound scan (USG). He had USG of his abdomen which did not reveal any abnormality. He underwent USG-guided fine needle aspiration cytology (FNAC) biopsy of his left testicular swelling, and pathology examination of the specimen showed occasional ill-formed epithelioid cell granulomas in a background of large amount necrosis and mixed inflammatory cells. Ziehl-Neelsen staining of pus and blood mixed particulate that was obtained by fine needle aspiration revealed acid-fast bacilli (AFB) [see figure 2]. FNAC of the enlarged inguinal lymph nodes on left side demonstrated granulomatous inflammation with caseation. Microscopy and biochemical examination of his urine was found to be normal. He underwent endoscopy examination of the lower urinary tract which was normal. Hence, the diagnosis was left sided isolated testicular tuberculosis (TB) with ipsilateral inguinal lymphadenopathy. As the patient did not have any history of anti-TB chemotherapy, category I anti-TB treatment regimen (thrice-weekly regimen which comprised of rifampicin: 450 mg/day, isoniazid: 600 mg/day, pyrazinamide: 1500 mg/day, and ethambutol: 1200 mg/day for first 2 months, followed by rifampicin and isoniazid for next 4 months) was provided as given therapy. Complete resolution of left testicular swelling and pain was observed and documented at the end of 6 months of his treatment.
Figure 1
Ultrasound of left testis showing a heteroechoic space occupying lesion. Reproduced from: [1]
Figure 2: Ziehl-Neelson staining of fine needle aspiration cytology materials obtained from the left testicular swelling showing two acid fast bacilli (x 100). Reproduced from [1]
Das et al. [1] made the ensuing summating discussions:
Badmos et al. [18] stated that isolated tuberculous epididymo-orchitis may closely simulate testicular tumour particularly in patients who have no history of systemic tuberculosis (TB) thereby presenting a diagnostic and therapy challenges. Badmos et al. [18] reported a 44-year-old man who had manifested with 4 months history of left scrotal mass for which he had undergone left orchidectomy following a presumptive diagnosis of testicular tumour. Histopathology diagnosis of tuberculosis of testis was subsequently made. Even though the patient was thereafter referred for antituberculosis treatment at the local tuberculosis treatment centre, he defaulted after commencing treatment. Badmos et al. [18] concluded that adequate evaluation of patients who have testicular mass by means of abdominal and scrotal ultrasound coupled with fine needle aspiration cytology is critical for the establishment of diagnostic accuracy, optimal treatment and possibility of avoiding surgery in those who have testicular tuberculosis.
Chiu et al. [19] stated that tuberculous epididymo-orchitis is an uncommon complication of intravesical bacillus Calmette–Guérin (BCG) immunotherapy for bladder cancer. Chiu et al. [19] reported a patient who had urinary bladder cancer and a history of intravesical BCG immunotherapy who had manifested with right scrotal pain for 1 week. A heterogeneous, hypoechoic, and solid mass encompassed by increased blood flow in the right testis was visualized upon scrotal echogram. His urine ordinary and tuberculosis culture yielded negative results. After failure of antibiotic therapy and the inability to exclude tumour, the diagnosis was confirmed by radical orchiectomy. Acid-fast staining of pus in the tumour and tumour tissue was positive, and a pus culture was positive for Mycobacteria tuberculosis complex. Right radical orchiectomy was undertaken, and anti-tuberculosis treatment with rifampicin, isoniazid, ethambutol, and pyrazinamide was provided. The patient was at the time of publication of the article under anti-tuberculosis treatment, and no significant adverse effects had been identified. Chiu et al. [19] advised that BCG-related epididymo-orchitis should be suspected in patients who have a history of intravesical BCG immunotherapy if the empiric antibiotic treatment typically used to treat common epididymo-orchitis has failed. Chiu et al. [19] made the following conclusions:
Sadeghi et al. [20] stated that Tuberculous epididymo-orchitis is a rare complication after intravesical bacilli Calmette-Guerin therapy for non-muscle invasive urinary bladder cancer and that spread of granulomatous disease via the genitourinary tract specifically to the testes does occur in 0.4% of treated patients. Sadeghi et al. [20] stated the following:
Sadeghi et al. [20] reported a 77-year-old man who had a history of benign prostatic hyperplasia as well as urothelial carcinoma of the urinary bladder who had manifested with testicular discomfort and a palpable mass two years ensuing his undergoing of intravesical instillations of BCG treatment, The patient initially had manifested with haematuria in 2017 and he underwent computed tomography (CT) (see figure 3a)) and post-CT abdominal radiograph in the excretory phase (see figure 3b), which had shown a soft tissue mass within the urinary bladder that was suspicious for urothelial carcinoma. This was confirmed visually during his cystoscopy procedure at which time the patient had undergone excision of the mass as well as transurethral resection of the urinary bladder tumour. Pathology examination of the surgical specimen demonstrated non-invasive high grade papillary urothelial carcinoma, stage Ta. In view of this, the patient was reported to be determined to be a candidate for BCG therapy and he was successfully treated with subsequent intravesical BCG instillations for 6 weeks followed by maintenance BCG instillation for 1 year.
Figure. 3a. Urogram phase CT performed on initial presentation for hematuria outlines an eccentric tissue mass at the base of the bladder suspicious for neoplasm. There is no lymphadenopathy in the pelvis. Reproduced from: [20]
Figure. 3b. Frontal abdominal radiograph obtained on initial presentation after intravenous contrast administration demonstrates filling defect at the base of the bladder. Trabeculation in the bladder wall is identified due to longstanding history of benign prostate prostatic hyperplasia and bladder outlet obstruction. Reproduced from [20]
Two years following his initiation of intravesical BCG therapy, the patient had complained of mild left testicular pain and a palpable mass. He had ultrasound scan of the testis which had demonstrated multiple vague hypoechoic lesions within his left epididymis (see figure 3a) and testis (see figures 3b to 4d) and fluid within his scrotal sac containing septations which were interpreted to be consistent in appearance with a complex hydrocoele (see figures 4a to 4d). His left testis was noted to be mildly hyperaemic in comparison with his right (see figures 4e to 4f) that was indicative of underlying infectious process. He had urinalysis which revealed small leukocyte esterase and urine culture which was negative. He was treated with routine antibiotic treatment for epididymyo-orchitis without significant improvement.
Figure 15 Reproduced from: [20]
Figures 4: Two years after TURBT and subsequent initiation intravesical BCG therapy, the patient presented with testicular pain and palpable abnormality. Sonographic image of the left testicle shows hypoechoic areas within the testicular parenchyma and a complex hydrocele (a-d). There is asymmetric hyperemia of the left testicle (e-f).Reproduced from: [20]
He underwent follow-up ultrasound scan imaging after his antibiotic therapy which demonstrated interval resolution of the complex hydrocele but increase in size and number of hypoechoic testicular lesions (see figures 5b and figure 5c). His urinalysis was again shown to be positive for leukocyte esterase and his urine culture was again negative. Discussion was undertaken between the urology and radiology teams regarding the patient's history and imaging findings which led to a differential diagnosis including sequalae of chronic infection such as testicular TB in light of prior intravesical BCG treatment. The results of his Serology tests were within normal limits including alpha feto-protein at 2.0 ng/mL, b-HCG at 1.0 mIU/mL, and lactate dehydrogenase at 162 U/L.
Figures 5. (a-c) Follow-up sonography 4 weeks later after antibiotic therapy shows resolution of complex hydrocele but increasing size and number of hypoechoic lesions in the left testicle. Reproduced from: [20]
Possibility of tuberculosis of the testis was raised after his initial failed antibiotic therapy.
Discussion with the patient regarding his treatment options led to the decision for him to undergo orchidectomy. Pathology examination of the radical orchiectomy specimen showed necrotizing and non-necrotizing granulomatous inflammation which had involved the testis, epididymis, and rete testis, with rare acid-fast bacilli forming a 4.5-cm dominant mass which was consistent with tuberculous epididymo-orchitis. Staining for acid fast bacilli demonstrated rare acid-fast bacilli (see figure 6a, figure 6b, and figure 6c).
Figure. 6a. Low power photomicrograph of orchiectomy specimen demonstrates areas of granulomatous and nongranulomatous inflammatory change and displacement of testicular parenchyma. Reproduced from: [20]
Figure. 6b. High power photomicrograph of orchiectomy specimen demonstrating giant cells suggestive of tuberculosis. Reproduced from: [20]
Figure. 6c. Acid fast stain showing sparse acid-fast bacilli. Reproduced from [20]
He underwent subsequent surveillance cystoscopy and biopsy of the urinary bladder tumour scar and pathology examination of the biopsy specimens showed predominantly denuded urothelial mucosa with mild chronic inflammation and reactive changes which were adjudged to be consistent with successful treatment of the tumour. He had follow-up urinalysis which was negative for leukocyte esterase suggesting successful treatment of testicular TB.
Sadeghi et al. [20] made the ensuing summative discussions:
Huang et al. [30] made the following conclusions:
E Sousa et al. [31] reported a 42-year-old immunocompetent male patient who had manifested with a 4-day history of unilateral right testicular pain. The patient had also complained of dry cough, asthenia and weight loss (9 kg) during the preceding 5 months. His laboratory test results revealed an elevated serum C-reactive protein (75mg/L) without leucocytosis/neutrophilia and mild anaemia (11.6g/dL). He underwent Doppler ultrasound scanning of the testis, which revealed that the right testicle was slightly enlarged with multiple small ill-defined hypoechoic parenchymal nodules (3 to 5mm) and the epididymis (body and tail) was diffusely enlarged and markedly hypoechoic with increased vascularization. The left testicle was unremarkable. He underwent Chest CT scan based upon his symptoms (long-standing dry cough and weight loss) and an abnormal chest x-ray, which had revealed multiple bilateral tree-in-bud parenchymal infiltrates within the upper lobes and upper segments of the lower lobes, as well as peri-bronchial consolidation areas and cylindrical bronchiectasis, which had suggested an endobronchial spread of pulmonary infection. Right pleural effusion and multiple enlarged paratracheal lymph nodes were also noted. E Sousa et al. [31] reported that pulmonary tuberculosis was confirmed with positive culture for Mycobacterium tuberculosis in bronchoalveolar lavage sample.
E Sousa et al. [31] made the following summations:
Clinical Perspective
With regard to clinical perspective, e Sousa et al. [31] made the ensuing iterations:
Imaging Perspective
With regard to imaging perspective, e Sousa et al. [31] stated the following:
Outcome
With regard to outcome e Sousa et al. [31] made the ensuing iterations:
Take-Home Message / Teaching Points
With regard to teaching points and take-home message, e-Sousa et al. [31] made the ensuing iteration:
Differential Diagnosis List
e-Sousa et al. [31] summated the differential diagnoses of tuberculous epididymoorchitis include the following:
e-Sousa et al. [31] stated that the final diagnosis of their patient was tuberculous epididymo-orchitis and pulmonary tuberculosis
Nepal et al. [35] made the ensuing relevant iterations related to Genitourinary tuberculosis (TB):
Nepal et al. [35] made the ensuing summative discussions:
Diffusely enlarged heterogeneously hypoechoic testis |
Diffusely enlarged homogeneously hypoechoic testis |
Nodular enlarged heterogeneously hypoechoic testis |
Multiple small hypoechoic nodules in the enlarged testis (miliary type) |
TB: Tuberculosis
Table 1: Gray scale sonographic patterns of testicular TB.
Figure 7: Various examples of gray scale sonographic patterns of testicular tuberculosis. (a) Diffusely enlarged right testis with heterogeneous hypoechoic pattern, (b) diffusely enlarged head (red arrow) and body (yellow arrow) of epididymis with infiltration of adjacent testes parenchyma (white arrows) showing homogenous hypoechoic pattern, (c) nodular enlarged heterogeneously hypoechoic testes, with ill-defined nodules (small white arrows) virtually indistinguishable from tumor, (d) ill-defined tiny hypoechoic nodules (black arrows) in testicular parenchyma. Reproduced from: [35]
Figure 8: A 44-year-old man with testicular tuberculosis who presented with 6 months history of testicular pain. (a) Gray scale sonographic image demonstrates an enlarged and heterogeneous testis with the presence of multiple ill-defined focal hypoechoic lesions (small yellow arrows). (b) Color Doppler shows increased vascularity along the periphery of the hypoechoic lesions. These imaging findings are non-specific and may be seen in both inflammatory and neoplastic conditions. A diagnosis of testicular tuberculosis was made the following orchiectomy. Reproduced from: [35]
Figure 9: A 42-year-old man with healed testicular tuberculosis: Gray scale sonographic image demonstrates smooth peripheral calcification along the tunica vaginalis (yellow arrows). The patient had a remote history of pulmonary tuberculosis, which was treated with antitubercular drugs.
Reproduced from: [35]
Specific ultrasound imaging features of testicular TB
[35] stated that with regard to specific ultrasound scan imaging features of TB of the testis, the following:
Figure 10: A 43-year-old male with complicated testicular tuberculosis presenting with scrotal pain and swelling. (a) Color Doppler sonographic image demonstrates diffuse, ill-defined heterogeneous hypoechoic area with increased peripheral vascularity but lack of central vascularity (yellow arrows). (b) Gray scale ultrasound image showing scrotal wall edema (black arrow) and multiseptated hydrocoele and debris (red arrow). (c) Contrast-enhanced axial computed image of abdomen in same patient shows hypoechoic lesions in the left lobe of live (red arrows) likely representing tubercular granulomas. Reproduced from [35][35] iterated the following:
Testicular TB simulators
With regard to the testicular TB simulators, Nepal et al. [35] iterated that imaging appearance of testicular TB is non-specific and it masquerades non-specific infection, inflammation, tumor, trauma, and infarct. Sarcoidosis
[35] stated the following with regard to sarcoidosis of testis and epididymis:
Figure 11: A 55-year-old male with sarcoidosis who presented with the right testicular pain. (a and b) Gray scale sonographic image of testis revealed several, tiny bilateral hypoechoic lesions (white arrows) on both testes (A-right, B-left testis). (c) Frontal chest radiograph shows the right hilar and paratracheal lymphadenopathy (yellow arrows) and bilateral interstitial and airspace opacities more on the right side. (d) Axial computed tomography chest image on lung window demonstrates asymmetric ground-glass opacities with surrounding pulmonary fibrosis and architecture distortion more prominent on the right. Reproduced from [35]
Lymphoma
[35] made the ensuing iterations related to Lymphoma of the testis / epididymis and TB of testis / epididymis:
Figure 12: A 70-year-old elderly male with lymphoma who presented with scrotal swelling (a) Gray scale ultrasound shows bilateral enlarged testes with bilateral hypoechoic masses (yellow arrows). (b) Note the diffuse involvement of the left testis by hypoechoic mass (annotated with red arrow). (c) color Doppler image showing profound vascularity concerning for tumor. A presumptive diagnosis of testicular tumor was made based on the patients age, clinical presentation, and sonographic findings. Histopathological examination of the left orchiectomy specimen revealed non-Hodgkin’s lymphoma. Reproduced from: [35]
Primary testicular tumors
[35] made the ensuing iterating summations related to Primary testicular tumours and TB of testis / epididymis:
Figure 13: A 30-year-old male with testicular tumor who presented with progressive right scrotal pain and swelling for a month. (a) Gray scale sonographic image demonstrates heterogeneous testis with multiple focal hypoechoic lesions with punctate calcifications (white arrows). The imaging features are simulating malignancy. (b) On color Doppler, peripheral and central vascularity is seen. This was found to be testicular undifferentiated sarcoma. Reproduced from: [35]
[35] also stated the following:
Testicular metastasis
[35] made the following summating iterations related to testicular metastases and TB of testis / epididymis:
Hematoma and infarcts
[35] made the ensuing iterations related to haematoma and infarcts of the testis as well as Tuberculosis of the testis / epididymis:
Figure 14: Tuberculosis mimics. A 20-year-old male with scrotal pain. (a) A well-defined heterogeneous hypoechoic lesion in lower pole of testes (white arrow) with peripheral flow on color Doppler. (b) Axial contrast-enhanced computed tomography abdomen of same patient revealed bulky conglomerate lymphadenopathy (yellow arrows) diagnosed as germ cell tumor. (c) A 16-year-old male with trauma. Irregular hypoechoic area in upper pole of testis (white arrows) with minimal hydrocoele. (d) A 35-year-old male for follow-up of testicular trauma. Avascular heterogeneous lesion in upper pole of testis (red arrow) diagnosed as hematoma. Reproduced from: [35]
Other infectious orchitis
[35] stated the following about other infectious orchitis and TB orchitis/epididymitis:
[35] made the ensuing summating iterations related to testicular adrenal rests and tuberculosis of the testis / epididymis:
Importance of extra-testicular ancillary findings
With regard to the importance of extra-testicular, Nepal et al. [35] stated the following:
Figure 15: Testicular tuberculosis mimicking tumor, importance of extra-testicular ancillary findings: (a) Gray scale sonography image of scrotum showing enlarged left testis with multi-focal ill-defined hypoechoic nodularity (yellow arrows). (b) Color Doppler shows increased vascularity. The left radical orchiectomy revealed caseous granulomatous orchitis and epididymitis. (c) Retrospective analysis of contrast-enhanced computed tomography (CT) abdomen shows calcified right adrenal gland (red arrow). (d) Chest-Xray was normal and (e) CT chest revealed bilateral lung parenchyma studded with multiple miliary tubercles. Reproduced from: [35] made the ensuing additional summating iterations:
Both TB and sarcoidosis are granulomatous diseases that are associated with overlapping radiology imaging findings.
Half of the cases of testicular TB will have active disease presentation, thus systemic evaluation and correlation could establish the diagnosis.
Nepal et al. [35] made the ensuing conclusions:
Kharbach et al. [49] stated the following:
[49] reported a 73-year-old Moroccan man who had manifested to their tertiary referral hospital after one week of left scrotal swelling. The patient did not have any history of tuberculosis or tubercular contact, and he did not have any significant medical history, he denied trauma and other symptoms. His clinical examination demonstrated a left testicular firm mass which measured about 3 cm, with irregular surface; scrotal skin and epididymis were normal on palpation. There was no palpable inguinal lymphadenopathy found during his examination. The results of his Serum tumour markers were within normal limits, AFP: 3.3 ng/mL; HCG: < 2 mUI/mL; LDH: 203 U/L. Serology for human immunodeficiency virus (HIV) was negative. He had chest radiograph which was within normal limits. He had scrotal ultrasound scan of the left testis which showed a heterogeneous, hypoechoic anterolateral mass that measured 28.9 mm × 14.7 mm in diameter (Figure 16), with internal vascularity upon colour Doppler imaging which had suggested testicular tumour (Figure 17). His right testis and both epididymes were normal upon his ultrasound scan of testes.
Figure 16
Ultrasonography of left testis showing a heterogeneous and hypoechoic mass measuring 28.9 × 14.7 mm in diameter. Reproduced from [49]
Figure 17
Color Doppler image showing internal vascularity of the testicular mass. Reproduced from: [49]
In light of these findings, left-sided high inguinal orchiectomy was undertaken (Figure 18) after an informed consent was obtained in view of the preliminary diagnosis of testicular tumour. Figure 18 Reproduced from: [54]
Figure. 18
Postoperative picture of orchiectomy. Reproduced from: [49]
Histopathological examination of testicular tissue revealed the presence of large areas of tuberculotic granuloma caseous necrosis ((Figure 19), multinucleated Langhans giant cells were present in the center of granuloma (Figure 20), and the epididymis was histologically normal. There was no evidence of malignancy.
Figure. 19
Photomicrograph showing granulomatous inflammation in testicular tissue, featuring caseous necrosis (H&E stain, × 100). Reproduced from: [49]
Figure 20
Photomicrograph showing epitheloid granuloma with multinucleated Langhans-type giant cells (H&E stain, × 40). Reproduced from: [49]
The results of his Acid-fast bacilli (AFB) sputum smear and cultures were negative. His Urine smear for AFB was negative, and his uroscan did not find any evidence of abnormality or urinary disorder, which had excluded an active site of genitourinary tuberculosis. Based upon the aforementioned findings, the patient was diagnosed as having isolated testicular TB.
The patient was referred at the local tuberculosis treatment centre. Anti-tuberculosis chemotherapy was then commenced for 6 months.
Kharbach et al. [49] made the ensuing summating discussions:
[49] made the ensuing conclusions:
Shugaba et al. [14] reported a 45-year-old man who had attended their visited their clinic with a painless swelling of his left scrotum and an ulcer as his chief complaints. A hard and indurated mass was found palpable with ulcerating foci which were proximal and distal, and which had measured 3 cm× 2 cm and 2 cm × 1 cm respectively and which were about 2 cm apart. The results of his laboratory data were normal except for an elevated erythrocyte sedimentation rate (ESR), and white blood cell (WBC) differential which had shown neutropenia and lymphocytosis. A diagnosis of left testicular tumour was made and the patient had undergone a left orchidectomy with fistulectomy. Histopathology examination of the left orchidectomy specimen showed a stratified squamous epithelium with tuberculous granuloma and necrotic caseation. At the time of the report of the case the patient was undertaking anti-tubercular medication. Shugaba et al. [14] pointed out that the rarity of this condition does make these findings important to report, so that clinicians could have a high index of suspicion for tuberculosis of the testis.
[58] stated the following:
Abraham et al. [58] reported the case of a 36-year-old Ecuadorian man who was residing in New York, New York, and who had manifested with a painful scrotal mass, weight loss, and purulent discharge from ulcerated lesion within his scrotal area 10 years following his immigration into the United States of America. The did not present with any other systemic symptoms. Positive QuantiFERON-TB Gold and radio imaging results had led to the diagnosis. After extensive workup, acid fast bacilli positive cultures which were obtained by computed tomography guided fine needle aspiration grew Mycobacterium tuberculosis complex. Anti-tuberculosis chemotherapy was commenced after sensitivity tests were confirmed. Significant recovery after 3 months of directly observed therapy was achieved.
[2022] [59] made the ensuing summations related to scrotal tuberculosis:
With regard to the radiography features of scrotal TB, Knipe et al. [59] had made the ensuing summating iterations:
Ultrasound
Tuberculous epididymitis.
Tuberculous orchitis
It is known that tuberculous orchitis does usually tend to be preceded or associated with epididymitis as well as different ultrasound scan patterns had been described including the ensuing: [15]
Other documented ultrasound scan of scrotal contents features
Other documented ultrasound scan of scrotal contents features that had been reported in cases of tuberculous epididymitis had been summated by Knipe et al. [59] to include the ensuing:
Treatment and prognosis associated with treatment of scrotal TB.
Differential diagnoses
Some of the documented differential diagnosis of intra-scrotal TB include the following:
Practical points to learn from
Some of the practical points related to scrotal tuberculosis which should be known and reflected upon include the ensuing:
Cherif et al. [60] stated the following:
Cherif et al. [60] reported a Caucasian HIV-positive heterosexual male with a clinical diagnosis of testicular tumour for which he had undergone a right orchidectomy. Tuberculous epididymo-orchitis was confirmed based upon histology examination of the orchidectomy specimen. Cherif et al. [60] iterated that in this case, all Immune Reconstitution Inflammatory Syndrome (IRIS) criteria were met. Cherif et al. [60] stated that they wanted to convey the message that in HIV-positive patients presenting with testicular swelling, an infective aetiology should be considered and that this will increase the possibility of early diagnosis and proper management.
El-Hamrouni et al. [61] described an unusual case of miliary tuberculous epididymo-orchitis following his undergoing a BCG-therapy, that simulated malignancy at his initial manifestation. They stated that genitourinary tuberculosis in a miliary pattern is rare, and their reported case report had emphasized the importance of meticulous analysis of the patient’s clinical history combined with imaging findings in order to ensure an adequate diagnosis and treatment.
Khan et al. [62] stated the following:
Khan et al. [62] reported a 32-year-old man who had a non-healing scrotal ulcer for which he underwent excision. Histopathology examination of specimens of the excised ulcer was consistent with features of tuberculosis (TB). Antitubercular therapy was administered and at the end of a year’s follow-up, there had been no evidence of recurrence. Khan et al. [62] made the ensuing conclusions:
Gangalakshmi et al. [63] stated the following:
Gangalakshmi et al. [63] reported the case of a 57-year-old male patient who had presented with ulcerative growth over his glans penis and who was clinically diagnosed as carcinoma penis; nevertheless, biopsy of the lesion upon pathology examination showed evidence of tuberculosis which was supported by chest X-ray. This narration has pointed out that even though rare, tuberculosis of the penis could be encountered on rare occasions.
Venyo [64] stated that tuberculosis of the penis (TBP) is rare. Venyo reviewed the literature related to tuberculosis of the penis in 2015 utilizing various internet data bases. Venyo [64] summarized aspects of tuberculosis of the penis as follows:
Venyo [64] iterated that close contacts of TBP patients should be screened and that extrapulmonary Tb should be excluded. Venyo [64] concluded that clinicians should consider the possibility of PTB in cases of penile lesions and erectile failure.
Rujaba et al. [65] iterated the following:
Rujaba et al. [65] reported a case of tuberculosis epididymo-orchitis and involvement of the left testis in a 37-year-old male patient. His left testicle had a heterogeneous parenchymal echo, and multiple hypo-echo and ill-defined areas were found within the left testis. In the colour Doppler ultrasound scan, the left testis with the epididymis on both sides was found to be completely hyperaemic. The findings were adjudged to be primarily in favour of extrapulmonary tuberculosis. Therefore, after a 2-month first-stage treatment with four-drug therapy of anti-TB drugs such as rifampin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg and ethambutol 275 mg, considering the weight of the patient (56 kg), 4 pills per day and the second phase of treatment with two-drug therapy, rifampin 150 mg and 75 mg of isoniazid, 4 pills per day for 4 months, and the extrapulmonary tuberculosis symptoms improved to a large extent. Rujaba et al. [65] concluded that in order to prevent epididymectomy and the effects that the disease might have on fertility, it should be tried to quickly diagnose and treat the disease at the same early stage of the disease.
Conflict of Interest - None
Acknowledgements
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