Teaching Case

Section

Uroradiology & genital male imaging

Case Type

Clinical Case

Authors

Ali S. F. Fadhil¹, Sahar Al-Talqani¹, Sumit Jagani²

¹ NHS Workforce, Training and Education – East Midlands, Nottingham, United Kingdom

² Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

Patient

6 years, male

Categories

Area of Interest Genital / Reproductive system male ; Imaging Technique Ultrasound ;

No Procedure ; No Special Focus ;

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Clinical History

A 6-year-old male presented with scrotal swelling with minimal pain, which was relieved with analgesia. There were no associated fevers or vomiting, nor history of trauma. Examination identified a non-tender 2cm x 3cm rounded firm rubbery mass anterior to the left testicle. There were no abnormal skin changes, normal cremasteric reflex, no hydrocele nor examination findings of hernia.

Differential Diagnosis List

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Polyorchidism

Testicular haemorrhagic cyst

Para testicular dermoid cyst

Hydroceles

Varicoceles

Spermatoceles

Tumours

Imaging Findings

US was performed with an 18–24MHz linear probe demonstrating normal appearances of the right hemiscrotum; fine granular echotexture of pre-pubertal testes measuring 13x7x8mm and relatively hypoechoic epididymis (Figure 1).

In the left hemiscrotum, there was a trilobed, ovoid structure with fine granular echotexture separated by thing hypoechogenic linear band (Figure 2). The lobes were isoechogenic to each other and similar to the right testes. There were mediastinum testes present in one of the lobules measuring 12x7mm in association with a relatively hypoechogenic epididymal head, thought to be the left testicle (Figure 3). The body and tail of the epididymis were distorted by the other lobules. The remaining ovoid structure 13x16x18mm had a central hyperechogenic band resembling mediastinum (Figure 4) but no communication to the epididymis. The findings were concerning for polyorchidism; however, on closer inspection, cine loop imaging demonstrated fine to-and-fro movement of echogenic material within the larger of the ovoid structure, favouring fluid content rather than testicular tissue, albeit incongruous with clinical findings. In light of this, the patient underwent surgical exploration and was found to have a haemorrhagic cyst containing old blood.

Discussion

Polyorchid is the condition of having more than 2 testes [1–3]. While the majority of cases are asymptomatic, a small number of patients may experience pain as their sole symptom [4]. The left side is more commonly affected by polyorchidism. Among all cases of supernumerary testes, triorchidism is the most frequently observed condition [5].

Sonography is usually sufficient for diagnosis in the majority of instances. However, an MRI may be useful in cases of complex polyorchidism [6]. Histology is the gold standard confirmation modality [7,8].

The typical imaging appearance of polyorchid involves normal echogenicity of the testes on scrotal ultrasonography. The supernumerary testis/testes can be observed as a solid nodule that is isoechoic to the testes and has the same echotexture [1,8]. Colour Doppler or power Doppler ultrasonography shows normal blood flow in the supernumerary testis, with the same characteristics as in the two normal ones [1,3,9]. Polyorchidism mimics or differentials include minor lobulation, para testicular dermoid cyst, hydroceles, varicoceles, spermatoceles, lipomas, tumours, hernia, and splenogonadal fusion [3,4,10,11].

In this case, it demonstrates that the blood could give a high echo signal which mimicked the polyorchidism picture radiologically [12]. The brief medical history exhibited atypical characteristics for polyorchidism, yet the absence of a triggering event such as trauma, combined with suspicious ultrasound features, raised concerns.

The management of polyorchidism remains a subject of debate, depending on factors such as testis location, reproductive potential, size, and age. Conservative surveillance is an option for orthotopic supernumerary testes, while surgical exploration is recommended for extra-scrotal testes or complications [13]. Conservative surveillance is now being accepted, particularly in pediatric cases with normal radiological findings and negative tumour markers [6,9,14,15].

Written informed patient consent for publication has been obtained.

References

[1] Rafailidis V, Elfeky M, Murphy A, et al. Polyorchidism. Reference article. Radiopaedia.org [Internet]. doi: 10.53347/rID-26484

[2] Balawender K, Wawrzyniak A, Kobos J, Golberg M, Żytkowski A, Zarzecki M, Walocha J, Bonczar M, Dubrowski A, Mazurek A, Clarke E, Polguj M, Wysiadecki G, Smędra A (2023) Polyorchidism: An Up-to-Date Systematic Review. J Clin Med 12(2):649. doi: 10.3390/jcm12020649. (PMID: 36675578)

[3] Artul S, Habib G (2014) Polyorchidism: two case reports and a review of the literature. J Med Case Rep 8:464. doi: 10.1186/1752-1947-8-464. (PMID: 25539715)

[4] Betancourt-Torres M, Figueroa-Diaz L, Rodriguez-Mojica W (2020) Paratesticular Dermoid Cyst Mimicking a Torsed Supernumerary Testis: A Case Report. Am J Case Rep 21:e923752. doi: 10.12659/AJCR.923752. (PMID: 33070146)

[5] Mummed FO, Endris AS, Erge MG (2021) Polyorchidism - An Incidental Finding During Orchidopexy: A Case Report and Review of the Literature. Res Rep Urol 13:811-14. doi: 10.2147/RRU.S342966. (PMID: 34820339)

[6] Dirie AM, Elmi AM, Mutlu E, Osman FAO, Mohamed AH (2022) Sonographically diagnosed and conservatively managed case of polyorchidism: A case report. Radiol Case Rep 17(8):2714-6. doi: 10.1016/j.radcr.2022.04.016. (PMID: 35669220)

[7] Teklali Y, Piolat C, Jacquier C, Nugues F, Dyon JF (2007) Polyorchidie chez l'enfant (à propos d'un cas avec revue de la littérature) [Polyorchidism in child (a case report and review of literature)]. Prog Urol 17(4):872-4. French. doi: 10.1016/s1166-7087(07)92312-x. (PMID: 17634006)

[8] Núñez García B, Álvarez García N, Pérez-Gaspar M, Esteva Miró C, Santiago Martínez S, Betancourth Alvarenga JE, San Vicente Vela B, Jiménez Gómez J, Jiménez Arribas P (2021) Polyorchidism in pediatric patients: a case report and a literature review. Cir Pediatr 34(3):160-3. English, Spanish. (PMID: 34254757)

[9] Ojaghzadeh D, Naji P, Ensannezhad A, Mahmoudpour M, Jalili J, Hakimzadeh Z (2022) Pentaorchidism diagnosed on ultrasound examination: A case report and literature review. Andrologia 54(5):e14389. doi: 10.1111/and.14389. (PMID: 35122296)

[10] Gharib MH, Zahedpasha R (2022) Minor lobulation of the testis, mimicking polyorchidism when inflammed, discussion of a rare case: A case report. Int J Surg Case Rep 97:107448. doi: 10.1016/j.ijscr.2022.107448. (PMID: 35907296)

[11] Ojaghzadeh D, Mahmoudpour M, Ezzati N, Akhavi Milani A (2021) Polyorchidism in ultrasound examination: A case report. Andrologia 53(1):e13832. doi: 10.1111/and.13832. (PMID: 32897591)

[12] Bickle I, Elfeky M, Weerakkody Y, et al. Scrotal haematocele. Reference article, Radiopaedia.org [Internet]. doi: 10.53347/rID-26153

[13] Savas M, Yeni E, Ciftci H, Cece H, Topal U, Utangac MM (2010) Polyorchidism: a three-case report and review of the literature. Andrologia 42(1):57-61. doi: 10.1111/j.1439-0272.2009.00957.x. (PMID: 20078517)

[14] Dushi G, Ramseyer P, Meyrat B, Frey P (2011) Polyorchidism in children. BJUI [Internet]. doi: 10.1002/BJUIw-2011-043-web

[15] Balawender K, Wiatr T, Wawrzyniak A, Orkisz S (2021) Management of Incidental Finding of Triorchidism Diagnosed During Routine Hernia Repair. Res Rep Urol 13:127-31. doi: 10.2147/RRU.S291621. (PMID: 33708748)

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