多次靜脈曲張結紮術後的持續性陰囊疼痛：肉芽腫性睪丸炎

鄭鼎耀¹、林祖鋒²

¹台北馬偕紀念醫院泌尿科；²新北市立聯合醫院泌尿科

Persistent Scrotal Pain Despite Varicocelectomy: Diagnosis of Granulomatous Orchitis Confirmed After Orchiectomy

Ting-Yao Cheng¹, Tsu-Feng Lin²

¹ Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan

² Department of Urology, New Taipei City Hospital, New Taipei City, Taiwan

Case presentation

A 49-year-old male presented with chronic right scrotal pain exacerbated by prolonged sitting and standing. The patient had a medical history of urolithiasis and hyperuricemia. He initially reported chronic right inguinal pain  with symptoms progressing on the right during extended walking. Scrotal ultrasound revealed a right varicocele, and he underwent microscopic right varicocelectomy in September 2022, with initial symptom relief. However, symptoms recurred by March 2023, presenting with a visual analog scale (VAS) pain score of 7-8 during prolonged sitting and 2 in general conditions. A second microscopic varicocelectomy, involving total testis exposure, was performed in May 2023, resulting in reduced pain, although mild soreness and numbness persisted.

By September 2023, the patient continued to experience persistent discomfort, prompting a scrotal ultrasound, which demonstrated atrophy of the right testis and fluid accumulation over the spermatic cord (Figure 1). Due to these findings and ongoing symptoms affecting his quality of life, the patient requested orchiectomy for symptom resolution. During his admission, he underwent a right radical orchiectomy. Histopathology showed non-specific granulomatous orchitis with testicular atrophy, consistent with varicocele. The internal spermatic vein and epididymis showed no specific pathological changes. Post-operative follow-up indicated symptom improvement.

Discussions

This case of granulomatous orchitis presented with chronic scrotal pain and progressive discomfort, ultimately necessitating orchiectomy for symptom relief. Granulomatous orchitis is a rare inflammatory condition that can mimic testicular tumors, making preoperative diagnosis challenging. The condition is often misdiagnosed as a testicular malignancy due to overlapping clinical and imaging features, as highlighted in the literature. Similar to the findings reported by Liu et al., conservative management with antibiotics or steroids has been largely ineffective, and orchiectomy is often required for both symptom control and diagnostic confirmation. In our case, the patient's persistent symptoms significantly affected his quality of life, prompting surgical intervention.

Histological examination revealed non-specific granulomatous inflammation with the presence of multinucleated giant cells, consistent with findings in the review by Roy et al., who described a similar pattern of inflammation involving granulomas and fibrosis. The exact etiology of granulomatous orchitis remains uncertain, though immune-mediated responses, trauma, or infections have been suggested as potential triggers. In our patient, the persistence of pain and scrotal discomfort, despite previous interventions, necessitated orchiectomy. This aligns with current understanding that orchiectomy is often the definitive treatment, particularly when the condition is resistant to conservative therapies.

In conclusion, granulomatous orchitis is a rare and challenging diagnosis that frequently necessitates surgical intervention due to its resemblance to malignancy and the ineffectiveness of conservative treatments. The overlap with malignancy in clinical presentation highlights the importance of histopathological examination to confirm the diagnosis and guide appropriate management. Orchiectomy not only provides symptom relief but also ensures exclusion of malignancy, which is crucial for optimizing patient outcomes.