Testicular Infarction and Rupture as an Uncommon Complication of Epididymo-Orchitis: A Case Report

We describe an unusual case of testicular infarction with tunica albuginea rupture occurring as a complication of multidrug-resistant Escherichia coli epididymo-orchitis in a 56-year-old man with poorly controlled type 2 diabetes mellitus. Clinical examination and routine laboratory testing cannot reliably distinguish complicated from uncomplicated epididymo-orchitis, and Doppler ultrasound is the key diagnostic tool. The patient presented with one week of progressive left scrotal pain and swelling that had failed to improve on outpatient oral antibiotic therapy. Examination demonstrated marked left hemiscrotal swelling with an absent cremasteric reflex; a tense, reactive hydrocele precluded testicular palpation. Scrotal ultrasound showed an enlarged, diffusely hypoechoic left testis (3.7 × 3.2 × 5.2 cm) with completely absent intratesticular Doppler flow, a large septated hydrocele, and a congested spermatic cord. Emergency scrotal exploration revealed turbid, foul-smelling fluid, breach of the tunica albuginea with extruded seminiferous tubules, and a non-viable dusky testis with no demonstrable flow on intraoperative Doppler, prompting left orchiectomy. Cultures grew multidrug-resistant Escherichia coli sensitive only to carbapenems. Recovery was uneventful. This case underscores that refractory or rapidly progressive epididymo-orchitis, particularly in patients with diabetes or other immunocompromising conditions, should prompt urgent re-imaging with Doppler ultrasound and a low threshold for surgical exploration, since absent intratesticular flow and tunica albuginea disruption mandate immediate operative intervention to prevent sepsis and to confirm tissue viability.