CASE REPORT

REPORTING AN UNUSUAL CASE OF INFERTILITY;

ISOLATED BILATERAL TUBERCULOUS
EPIDIDYMO-ORCHITIS
Hasham Akram Choudhary∗ , Shareen Altaf∗ , Benish Zeeshan∗ , Naila Jabbar∗ and Zeeshan Akram∗
∗ Department of Surgery & Gynecology, Jinnah Hospital, Allama Iqbal Medical College Lahore, Pakistan.

ABSTRACT
Tuberculosis may infect any part of the body. Tuberculous orchitis is a rare disease that usually occurs as a result of direct
extension from the epididymis. Only a paucity of cases regarding epididymo-orchitis and scrotal involvement without
renal or pulmonary involvement has been reported until today. Isolated tuberculous epididymo-orchitis presents with
a clinical picture and radiographic illustrations mimicking a scrotal neoplasm; therefore, diagnosis can be challenging
for physicians. We are presenting a case of isolated bilateral tuberculous epidymo-orchitis resulting in infertility and
discharging scrotal sinuses which responded to 6 months anti – tuberculous therapy.
KEYWORDS: Scrotal sinuses, infertility, tuberculous epididymo-orchitis, extra pulmonary tuberculosis.

kinds of tuberculous manifestations.[6] TB of the scrotum is rare,

Introduction
Tuberculosis (TB) is a widespread, and in many cases fatal, infec-
tious disease caused by different strains of mycobacteria, usually
Mycobacterium tuberculosis.[1] TB has a close association with
both overcrowding and malnutrition, making it one of the prin-
cipal diseases of poverty. [2] Mycobacterium tuberculosis infects
about one-third of the world population and kills about three
million patients per annum thus becomes the single most im-
portant infectious cause of death on Earth.[3] About 1% of new
cases are infected each year.[4] Tuberculosis may infect any part
of the body, but the most common type is pulmonary tuberculo-
sis.[5] When tuberculosis develops outside of the lungs, this is
referred to as extra pulmonary tuberculosis which may coexist
with pulmonary TB.[5] In 15–20% of active cases of pulmonary
TB, the mycobacteria spread outside the lungs, causing other
Copyright © 2018 by the Bulgarian Association of Young Surgeons
DOI:10.5455/ijsm.isolated-bilateral-tuberculous-epididymo-orchitis
First Received: April 15, 2017
Accepted: July 08, 2017
Manuscript Associate Editor: George Baitchev (BG)
Editor-in Chief: Ivan Inkov (BG)
Reviewers: Senol Tonyali (TR)
1
Letterkenny University Hospital, Letterkenny – Co. Donegal, The Republic of Ireland.
hashamakram@hotmail.com
occurring in about 7% of TB patients.[7] Tuberculous orchitis is
a rare disease that usually occurs as a result of direct extension
from the epididymis.[8] Isolated tuberculous epididymo-orchitis
presents with a clinical picture and radiographic illustrations
mimicking a scrotal neoplasm; therefore, diagnosis can be chal-
lenging for physicians.
Case report
Mr AH, a 25 years-old-male of average built presented to the sur-
gical OPD in July’ 2015. A year ago, just before getting married,
he noticed a single discharging sinus over his right hemiscrotum.
The discharge was viscous, pale white in colour, odourless, and
soaked one small dressing per 24 hours. There was no associated
pain, swelling, itching, fever or dysuria. Neither had he noticed
any sexual dysfunction. He ignored it and did not seek any
expert advice.
Other than that his brother suffered from pulmonary TB in
the past, there was no significant disease history in the family.
Later two months after his marriage he noticed two more sinuses
on the same side of the scrotum. This worried him, and he went
to some quack who advised some topical ointments. This did
not help much, and a few months later a similar sinus appeared
on the left hemiscrotum.
This time he visited a General Physician (GP) for an opinion
who prescribed some antibiotics for two weeks. The discharge

Hasham Akram Choudhary et al./ International Journal of Surgery and Medicine (2018) 4(3):167-169
stopped transiently for a few days with this antibiotic course but
never settled completely, and as there was no other symptom,
he stopped bothering with it.
Meanwhile, as his wife did not conceive after 11 months of
marital life despite wishes, they visited Jinnah Hospital Lahore
infertility clinic, where complete examination and investigations
of the couple were carried out. Interestingly his semen analysis
showed no spermatozoa. He was referred for surgical consulta-
tion for evaluation of the scrotal sinuses. (Fig. 1).
Fig. 1. Discharging sinuses on both sides of scrotum.
On examination, both testis were of normal size, shape and
consistency on clinical examination but right hemiscrotum ap-
peared a bit enlarged, suggestive of a moderate amount of lax
hydrocele clinically. There was no associated regional lym-
phadenopathy. Rest of the systemic examination was unremark-
able.
Baseline laboratory investigations including urine analysis
were all normal, except a raised ESR count. AFP, Beta HCG and
LDH were within normal range. Urine culture did not show
any growth. Scrotal ultrasound revealed scrotal skin oedema
and moderate right sided hydrocele. Both testis was normal
in size but had multiple, bilateral sub centimetric ill-defined
hypoechoic foci; both epididymal heads were also enlarged.
Abdominopelvic ultrasound was normal. Chest X-ray was done
to rule out pulmonary TB and was normal.
Tissue diagnosis was considered inevitable by the sur-
geon, and histopathology report of his testicular wedge biopsy
showed typical features of TB, i.e. granulomas, with epithelioid
macrophages and Langhans giant cells along with characteristic
caseous necrosis in the centre.
Hasham Akram Choudhary et al./ International Journal of Surgery and Medicine (2018) 4(3):167-169
The patients were diagnosed as a case of isolated tuberculous
epididymo-orchitis as there was no sign of disease elsewhere.
He was commenced on anti- TB therapy, i.e. three anti-TB drugs
given daily for three months followed by two drugs for the
next three months. Regular follow-ups showed complete res-
olution of the discharging sinuses at the end of therapy. More
interestingly his semen analysis report showed the presence of
spermatozoa four months after finishing the anti-TB course.
Discussion
The most common site of genital TB is the epididymis. However,
testicular tuberculosis is rare. [9] Usually, testicular involvement
is as a result of local invasion from the epididymis or retrograde
seeding from the epididymis and rarely by the blood-borne
spread.[9] Only a small number of cases have been reported until
today regarding epididymo-orchitis and scrotal involvement
without renal or pulmonary involvement.[7,10]
Isolated tuberculous epididymitis usually presents without
specific clinical symptoms in young men under the age of 40, and
there are high chances to be wrongly diagnosed as a testicular
tumour.[11] Clinical manifestations may include fever, increased
urinary frequency, flank pain, dysuria with sterile pyuria or
hematuria, suprapubic pain or a painless testicular mass [10,12].
There may be present associated tuberculous prostatitis and
seminal vesiculitis, and it is believed that epididymo-orchitis
usually represents a secondary spread from these other areas of
the genital tract.[14] This results in thickening and the forma-
tion of a caseous mass which is very dense initially, but after a
certain amount of time they generally liquefy and tend to burst
externally, resulting in fistulae formation.
Urine cultures can be negative (for bacilli) in most of the
specimens.[8] Though ultrasound has been traditionally the
diagnostic method of choice for investigation of tuberculous
epididymo-orchitis, eight but in the absence of histological evi-
dence, the diagnosis of TB testis cannot be ascertained. [15] If
diagnosed correctly, isolated tuberculous epididymitis can be
potentially cured by anti-TB medications. Treatment of uncom-
plicated genito-urinary TB consists of the combination therapy
for six months. In specific cases like immunosuppressed/ hu-
man immunodeficiency virus patients or case recurrence, the
treatment should be extended to a period of 9–12 months.[13]
Some authors suggest the injection of intra-tunical Rifampicin as
an alternative therapy of isolated tuberculous epididymitis.[7]
Surgical resection is usually reserved for those patients who are
refractory to medical therapy. [8] Patients with testicular masses
should be thoroughly investigated preoperatively and postoper-
atively to increase the diagnostic index of this condition.
Conclusion
Especially for tuberculous epididimo-orchitis where urine cul-
tures can be negative for bacilli, and there are no clinical symp-
toms from other organs or systems, diagnosis is even more diffi-
cult. Moreover, radiographic illustrations cannot differentially
diagnose isolated testicular TB from malignant diseases. Our
case highlights these clinical challenges and the necessity of a
thorough diagnostic workup to avoid an unnecessary orchiec-
tomy.
Authors’ Statements
Competing Interests The authors declare no conflict of interest.
 The patient has granted her written and informed consent
for publication of this material.

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Hasham Akram Choudhary et al./ International Journal of Surgery and Medicine (2018) 4(3):167-169