A Systematic Review on the Presentation and Management of Segmental Testicular Infarction.

BACKGROUND

Segmental testicular infarction (STI) is a rare and likely underdiagnosed cause of acute scrotal pain. Its clinical and imaging presentation often mimics testicular torsion or malignancy, frequently leading to unnecessary surgical intervention.

OBJECTIVES

To review reported cases of STI, characterize clinical presentation, imaging features, management strategies, and outcomes, and identify factors associated with diagnostic accuracy and conservative management.

MATERIALS AND

METHODS

A systematic review was conducted using PubMed and Embase databases, in accordance with PRISMA guidelines. Case reports and case series describing STI were included. Demographic, clinical, imaging, management, and outcome data were extracted. Descriptive and comparative analyses were performed. Factors associated with management were assessed using univariate logistic regression, and predictors of diagnostic accuracy were identified using a Classification and Regression Tree (CART) analysis.

RESULTS

Seventy-five studies comprising 99 patients were included. Median age was 34.0 years, and 87.9% presented with acute unilateral scrotal pain. Only 31.3% of cases were initially diagnosed as STI, most commonly being misdiagnosed as testicular tumor or torsion. Ultrasound was the primary imaging modality; low or absent Doppler flow was associated with correct diagnosis and conservative management (OR = 0.26 [0.10-0.68]). Overall, 42.4% of patients were managed conservatively while 30.3% had a total orchiectomy. Misdiagnosis was strongly associated with surgical intervention (p < 0.001). Long-term outcomes did not differ significantly between conservative and surgical management. CART analysis identified palpable mass, imaging strategy, lesion morphology, age, and symptom duration as key contributors to diagnostic accuracy (sensitivity 54%, specificity 46%).

DISCUSSION: STI remains frequently misdiagnosed due to overlapping clinical and imaging features with more common testicular pathologies. Diagnostic uncertainty, rather than disease severity, largely drives surgical management.

CONCLUSION

Increased awareness, careful interpretation of Doppler ultrasound findings, and structured diagnostic pathways may facilitate safe conservative management and testicular preservation in patients presenting with scrotal pain.