Acute scrotal pain with a twist.

Intratesticular lesions identified on ultrasound are usually malignant. It presents a particular dilemma to the surgeon when conservative approach is considered. A 55-year-old smoker with peripheral vascular disease had attended the accident and emergency with acute left hemiscrotal pain of 24-h duration. Clinical examination revealed a swollen, tender hemiscrotum. Ultrasound had demonstrated a hypo-echoic lesion in the testis measuring 2 x 1.8 cm. This was reported as possible infarct and managed conservatively. On review after 4 weeks, the patient was still symptomatic with persistent dull pain. A repeat scan in 4 weeks showed persistence of the lesion raising the possibility of tumour. Tumour marker profile was not elevated. The patient had a radical orchidectomy and the histology showed segmental infarction of the testis with thrombosis of the segmental testicular vessels. Peripheral vascular disease can cause segmental infarction of the testis due to the end arterial blood supply; in these cases, magnetic resonance scan can be diagnostic. Once confirmed, segmental infarcts can be safely managed conservatively.