Handa et al.

17

Tropical Doctor
2018, Vol. 48(1) 17–20
Granulomatous epididymo-orchitis: ! The Author(s) 2017
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DOI: 10.1177/0049475517711017
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Uma Handa1, Reetu Kundu2, Gunjan Raghubanshi3 and

Vidur Bhalla4

Abstract
Tuberculosis is the leading cause of chronic granulomatous epididymo-orchitis in the Asian population. A retrospective
analysis of 40 patients diagnosed with granulomatous or tubercular epididymo-orchitis on fine-needle aspiration (FNA) was
carried out. May Grünwald giemsa, haematoxylin and eosin and Ziehl Neelsen stained smears were evaluated. Of 40 patients
studied, aspiration smears showed epithelioid cell granulomas with caseation in 17, granulomas alone in 19 and caseation
only in four. Acid fast bacilli were seen in 15. Cytologic diagnoses rendered were tubercular epididymo-orchitis in 15,
granulomatous inflammation suggestive of tuberculosis in six and granulomatous inflammation in 19. FNA may readily
diagnose tubercular epididymo-orchitis and may avoid unnecessary orchidectomy in a good number of patients.

Keywords
Fine-needle aspiration, granulomatous epididymo-orchitis, tubercular epididymo-orchitis

Introduction and stained with May Grünwald giemsa and haematoxy-

Granulomatous epididymo-orchitis is a term that
encompasses a group of pathologies with different aeti-
ology.1 Tuberculosis (TB) is the most common cause in
low- and middle-income countries.2,3 Involvement of the
epididymis is fairly common while the testis is rarely
involved, but the latter is often mistaken as a malig-
nancy.4 Fine needle aspiration (FNA) is a minimally
invasive diagnostic modality and the aim of our study
was to evaluate the cytomorphology of granulomatous
epididymo-orchitis. The findings were correlated with
the nature of material aspirated and the status of acid
fast bacilli (AFB) on Ziehl Neelsen (ZN) staining.
Patients and methods
Ours was a retrospective study of 40 patients diagnosed
with granulomatous or tuberculous epididymo-orchitis
on FNA between January 2002 and December 2015.
FNA was performed as an outpatient procedure,
whose details were explained to, and informed consent
obtained from, the patient beforehand. In a relaxed
supine position, the patient’s scrotum was prepared
with 5% betadine solution, and the suspect swelling or
nodule was fixed between index finger and thumb before
aspirating, using a 23G needle attached to a 10-mL dis-
posable syringe mounted on a syringe holder, with the
other hand. There were no significant complications
noted. Both air-dried and wet-fixed smears were made
lin and eosin (H&E), respectively. ZN staining for AFB
was also performed in all the cases. Periodic acid Schiff
staining (PAS) was carried in AFB-negative cases to rule
out a fungal aetiology. FNA findings were correlated
with the histopathology wherever available. Following
the cytological diagnosis of granulomatous or tubercular
epididymo-orchitis, patients underwent clinical workup
including erythrocyte sedimentation rate (ESR), chest
radiography, sputum cytology, Mantoux testing and
abdominal, pelvic and scrotal ultrasonography.
Results
Patients were in the age range of 16–70 years. Data are
shown in Table 1. Correlation between material aspi-
rated from and cytologic features of smears in testicular
1
Professor and Head, Department of Pathology, Government Medical
College and Hospital, Chandigarh, India
2
Senior Lecturer, Department of Pathology, Government Medical College
and Hospital, Chandigarh, India
3
Senior Resident, Department of Pathology, Government Medical
College and Hospital, Chandigarh, India
4
Associate Professor, Department of General Surgery, Government
Medical College and Hospital, Chandigarh, India
Corresponding author:
Reetu Kundu, Senior Lecturer, Department of Pathology, Government
Medical College and Hospital, Sector 32-A, Chandigarh 160030, India.
Email: reetukundu@gmail.com
18 Tropical Doctor 48(1)

or epididymal swellings is shown in Table 2. Epithelioid
cell granulomas (Figure 1), caseous necrosis (Figure 2),
mixed inflammatory cells, Langhans’ giant cells, fibro-
blasts, granulation tissue and epididymal cells were seen
in varying proportions. Careful search for AFB on
ZN-stained smears showed positivity (Figure 2) in 15
patients (37.5%). PAS smears searching for fungal
elements in AFB negative patients were all negative.
Findings of healed pulmonary TB were observed on
chest radiography in four patients. The Mantoux test
was positive in 26 while ESR was raised in 19. Of 16
cases with a clinical diagnosis of testicular neoplasm,
biopsy was done in four and an orchidectomy specimen
was reviewed in one instance. The histopathological
diagnosis in all these cases was granulomatous inflam-
mation suggestive of TB. Polymerase chain reaction
(PCR) testing was not done owing to cost constraints.
All the patients were started on anti-tubercular therapy
(ATT) comprising rifampicin, isoniazid (INH), etham-
butol and pyrazinamide in standard doses for two
months with continuation of rifampicin and INH for
another four months. After initiation of ATT, local and
constitutional symptomatic relief with a gradual
decrease in scrotal swelling was seen in all but one
patient in whom orchidectomy was performed.
Discussion
A painless, solid testicular or scrotal lump is generally
considered malignant with only rare exceptions,2
which may be grouped under infective and non-infective
causes of granulomatous epididymo-orchitis.5–7 Its varied

Table 1. Symptoms and signs of patients with presumptive

clinical diagnosis.

Presumptive Patients
Symptoms and signs clinical diagnosis (n (%))

Painless epididymal and Neoplasm 16 (40)

testicular lump
Epididymal nodule along Tubercular 9 (22.5)
with fever epididymo-orchitis
Tender epididymal Chronic 12 (30)
nodule epididymo-orchitis
Epididymal and testicular Tubercular 2 (5)
enlargement with epididymo-orchitis
inguinal
lymphadenopathy
Epididymal and testicular Chronic 1 (2.5)
nodules with epididymo-orchitis Figure 1. FNA smear showing epithelioid cell granuloma (May
infertility Grünwald giemsa 400).

Table 2. Correlation between material aspirated and cytologic features of smears in testicular/epididymal swellings (n ¼ 40).

Cytological features

Epithelioid cell
Material aspirated; granuloma Epithelioid cell AFB status;
patients (n (%)) Caseation with caseation granuloma patients (n (%)) Aspiration diagnosis

Purulent; 16 (40) 4 12 0 Positive; 12 (75) Tubercular epididymo-orchitis

Negative; 4 (25) Granulomatous inflammation
suggestive of TB
Cheesy/necrotic; 3 (7.5) 0 3 0 Positive; 3 (100) Tubercular epididymo-orchitis
Mixed with blood; 12 (30) 0 2 10 Negative; 2 (16.7) Granulomatous inflammation
suggestive of TB
Negative; 10 (83.3) Granulomatous inflammation
Drop of fluid; 9 (22.5) 0 0 9 Negative; 9 (100) Granulomatous inflammation
Handa et al.
Figure 2. Aspirate showing large areas of caseous necrosis in
tubercular epididymo-orchitis (May Grünwald giemsa 100).
Inset shows acid fast bacilli (ZN 1000).
aetiology includes TB, brucellosis, syphilis, lepromatous
leprosy, fungal infection, sarcoidosis, malakoplakia and
xanthogranulomatous, and idiopathic changes.1 TB is by
far the most common.2 The most common clinical pres-
entation was that of a firm to hard scrotal nodule.8–10 In
60% of cases, a presumptive diagnosis of TB was made
on the basis of other associated symptoms or signs but in
40% a testicular neoplasm was suspected. One single
patient presented with infertility, an uncommon compli-
cation of male genital TB.4
Ultrasonographic findings of a testicular tumour and
granulomatous epididymo-orchitis are very similar, as
both may show an enlarged heterogeneous testis with
deformation of testicular contour.11 The presence of
epithelioid cell granulomas, Langhans’ giant cells,
caseous necrosis and positivity for AFB are diagnostic
features confirming tubercular epididymo-orchitis.
We found AFB in patients with purulent or cheesy
aspirate, while those with blood mixed or entirely
fluid aspirates were AFB-negative. AFB culture
remains the gold standard for diagnosing TB but
takes six to eight weeks for isolation, by which time a
patient is often lost to follow-up. PCR may facilitate
the diagnosis.12 However, the setup is often still want-
ing owing to cost constraints.
Where TB is endemic and no definitive diagnosis has
been made, a final diagnosis of granulomatous inflam-
mation suggestive of TB may still be entertained.13 In
our study, 19 cases (47.5%) were AFB-negative and
lacked caseation. Evaluating PAS smears may be help-
ful in this situation. An absence of sperm fragments and
macrophages containing engulfed spermatozoids is
helpful in excluding spermatic granuloma.14 Careful
search for tumour cells should also be made in each
case to exclude a testicular tumour. Inflammation and
necrosis may be seen in embryonal carcinoma and
19
seminoma.15 Furthermore, the presence of plentiful
lymphocytes in association with epithelioid cells or
granulomas mandates the exclusion of a seminoma.
TB is a great mimicker of neoplasm. Thus, a histo-
pathological diagnosis of tubercular epididymo-orchitis
in an orchidectomy specimen is no surprise.16 We found
one such case in our study, but almost always repre-
sents an unwarranted and unjustifiable intervention.
The potential risk after FNA of tumour seeding in
the needle track is unproven.15,17,18 To the contrary,
FNA may help by suggesting the correct surgical
approach depending on tumour type.19 FNA offers sev-
eral advantages over a testicular biopsy besides being
cost-effective.18 A biopsy specimen may anyway not be
representative and artefacts may make correct interpret-
ation problematic. A quick, reliable diagnosis with FNA
in conjunction with ZN staining, however, will usually
produce an early tissue diagnosis and enable prompt
treatment to be instigated. In the case a testicular
tumour is detected on FNA, immediate surgery with
excision of needle track can follow.20
Conclusion
TB is the leading cause of chronic granulomatous epi-
didymo-orchitis in many parts of the world. It is com-
monly mistaken as a testicular tumour both clinically
and radiologically. FNA is a minimally invasive modal-
ity which can provide quick diagnosis facilitating med-
ical treatment. Hence, unnecessary orchidectomy can
usually be avoided.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Keywords
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1
MD, FACS, Department of General Surgery, Adana Research and
Teaching Centre, Baskent University, Adana, Turkey
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Tropical Doctor
2018, Vol. 48(1) 20–24
! The Author(s) 2017
Reprints and permissions:
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DOI: 10.1177/0049475517717177
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2
MD, Department of General Surgery, Adana Research and Teaching
Centre, Baskent University, Adana, Turkey
Corresponding author:
Nezih Akkapulu, Department of General Surgery, Adana Research and
Teaching Centre, Baskent University, Dadaloglu Mh. 39 Sk. No. 6 Yuregir,
01250 Adana, Turkey.
Email: akkapulu@gmail.com