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Year : 2021  |  Volume : 28  |  Issue : 1  |  Page : 21-23

Testicular microlithiasis seen in primary infertility

1 Department of Radiology, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Radiology, Ahmadu Bello Teaching Hospital, Zaria, Nigeria

Date of Submission20-Nov-2019
Date of Acceptance18-Sep-2020
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. John Sheyin
Department of Radiology, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Kaduna
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wajr.wajr_31_19

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Testicular microlithiasis (TM) is rare and usually asymptomatic. It is usually bilateral but has been reported on single testis. TM is defined as five microliths on a single sonogram; it is divided into classical TM and limited TM. There is association between TM and neoplasm. A 34-year-old male presented with a history of primary infertility. Investigations done were normal, except for semen analysis and scrotal ultrasound. The scrotal scan showed multiple hyperechoic foci in both testes. The patient did not come for follow-up in the clinic. Ultrasound is used to diagnose TM in a case of infertility

Keywords: Hyperechoic foci, infertility, testicular microlithiasis

How to cite this article:
Sheyin J, Chom ND. Testicular microlithiasis seen in primary infertility. West Afr J Radiol 2021;28:21-3

How to cite this URL:
Sheyin J, Chom ND. Testicular microlithiasis seen in primary infertility. West Afr J Radiol [serial online] 2021 [cited 2022 May 24];28:21-3. Available from: https://www.wajradiology.org/text.asp?2021/28/1/21/314228

  Introduction Top

Testicular microlithiasis (TM) is rare and usually asymptomatic.[1],[2] It was first reported by Priebe and Garret in 1970 in a healthy 4-year-old child.[1],[3] With increasing pathologic awareness came the first description of its sonographic appearances by Doherty et al.[4] in 1987.[1],[2],[5] Sonographic TM appears as small, nonshadowing hyperechoic foci ranging in diameter from 1 to 3 mm. This occurs within the testicular parenchymal but may be distributed peripherally or segmentally. TM usually occurs bilaterally but has been reported in a single testis.[1],[2],[3],[5],[6] The number of microliths required to define TM has been arbitrary, but the consensus now is to accept five on a single sonogram. Classification of TM is into two; the classical TM (CTM) or limited TM (LTM) which also have two definitions. CTM is defined as when there is five or more multiple hyperechoic foci in a single sonogram and LTM is when they are <5; however, Doherty[4] and Jaramillo[7] defined CTM as when the microliths are randomly distributed throughout the testicle while LTM is when they are limited to a part of the testicle.[8] Its prevalence is 0.05%–18.1%[1],[3],[5],[6],[8] There is both accrued and largely anecdotal evidence of an association between TM, intratubular germ cell neoplasia, and testicular tumor.[1],[2],[3],[5],[6],[8],[9],[10],[11],[12]

  Case Report Top

El is a 34-year-old banker who was referred from a private hospital in Kaduna to Ahmadu Bello University Teaching Hospital with a history of infertility for a period of 2 years. On examination, a young man is afebrile, anicteric, and not dehydrated.

Review of the systems yielded no additional information. They were essentially normal. Investigations ordered include full blood count and differentials, urine microscopy, culture and sensitivity (m/c/s), urea and electrolytes and random blood sugar, transrectal ultrasound, scrotal ultrasound (SUS), serum hormones, and semen analysis (SA). Except for SA and SUS, the remaining investigations were essentially normal.

The SA showed scanty spermatozoa. Their total count was <1.0 × 106 cells/ml. None was mobile. Their morphologies also showed only 20% that were in their normal form. Pus cells count was 80–82/HPF.

The SUS showed normal-sized testicles, measuring 4.0 cm × 2.0 cm and 3.9 cm × 2.2 cm in their dimensions for the right and left, respectively. There were multiple, nonshadowing hyperechoic foci seen all over in both testicles, being worst on the left side. On color interrogation, there was flow of blood in the epididymides and testicles. There was no intratesticular mass, varicocele, or hydrocele noted on either side. A radiological diagnosis of TM was made [Figure 1] and [Figure 2]. The patient absconded, i.e., was not seen again in the clinic.
Figure 1: Right testicle showing multiple echogenic foci

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Figure 2: Left testicle also showing multiple echogenic foci

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  Discussion Top

The actual cause of TM is unknown but its pathologic appearance is due to degeneration of the semiferius epithelium rubbing into the tubular lumen. The debris which has been secreted into the lumen accumulates there in the form of a glycoprotein and calcium layers and evolves into the histologically characteristic form.[5],[9],[12] Its prevalence is 0.05%–18.1%.[1],[3],[5],[6],[8] The number of pediatric cases is relatively smaller when compared to adults.[3],[10] This patient was an adult. They develop in the testicular parenchyma; however, they may show peripheral or segmentary distribution. Although they are usually bilateral, unilateral TM cases have been reported.[1],[3],[5],[6] It was bilateral in this case. TM is classified into CTM in which the number of microliths is five or more and LTM in which they are <5.[1],[11] It was CTM in this case.

TM has been associated with the number of diseases such as inflammatory scars, granulomata, and infarction with hemorrhage. Similarly, variable testicular calcification is often seen sonographically within testicular tumor, but they do not tend to show the characteristic configuration of TM as previously described. Co-existence of much benign and malignant pathology with TM such as cryptorchidism, pulmonary alveolar, microlithiasis, male pseudohermaphroditism, Klinefelter syndrome, AIDS, germ cell tumors, Down syndrome, and infertility has been reported.[3],[5],[9],[12] The index patient here presented with primary infertility. Other associations include previous radiotherapy. Testicular neoplasm is an important association. These are only association and no cause-and-effect relationship has been established. Indeed, TM may simply act as a marker of an abnormal testis affected by a range of abnormal processes, all of which may in their own right be associated with testicular malignancy.[1] Malignancy can occur in any of TM.[12] Only infertility was found in this patient.

The significance of an association between abdominal or thoracic teratomas and TM remains unclear; due to these associations related to TM, abdominal ultrasound, chest, and abdominal X-rays should be done to rule out their involvement, which were not done in this case. TM should be considered a premalignant condition. The use of serial ultrasound and tumor markers for monitory and biopsy may be warranted at intervals. Treatment is mainly conservative, but surgery (orchiectomy) is done when indicated.

  Summary Top

A case of TM in a 34-year-old man has been presented. Its clinical features, radiological diagnosis, and review of the literature have also been discussed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Cast JE, Nelson WM, Early AS, Biyani S, Cooksey G, Warnock NG, et al. Testicular microlithiasis: Prevalence and tumour risk in a population referred for scrotal sonography. AJR Am J Roentgenol 2000;75:1057-60.  Back to cited text no. 1
Okere PC, Ani N, Iloanusi NI, Itanyi DU, Okoye IJ, Olusina DB. Testicular microlithiasis: How concerned should we be? West Afr J Radiol 2011;18:10-5.  Back to cited text no. 2
  [Full text]  
Murat K, Ugur B, Mutlus NB, Taner U, Ibrahim S. Testicular microlithiasis in paediatric age group: Ultrasonography and literature review. Diagn Interv Radiol 2005;11:60-5.  Back to cited text no. 3
Doherty FJ, Mullins TL,Sant GR. Drinkwater MA,Ucci AA. Testicular microlithiasis- a sonographic appearance. J ultrasound Med, 1987; 6:389-92.  Back to cited text no. 4
Backus ML, Mack LA, Middleton WD, Kind BF, Winter TC, True LD. Testicular microlithiasis. Imaging appearances and pathologic correlation. Radiology 1994;192:781-5.  Back to cited text no. 5
Hobarth K, Susani M, Szabo N, Kratzic C. Incidence of testicular microlithiasis. Urology 1992;40:464-7.  Back to cited text no. 6
Jaramillo D, Perez-Atayde, Teele RL. Sonography of testicular microlithiasis. Urol Radiol, 1989;11:55-7  Back to cited text no. 7
Selim S, Bilal G, Murat U, Ozum T, Serdar T, Veli A, et al. Prevalence testicular microlithiasis in an asymptotic population. Scandinavian J Urol Nephrol 2006;40:212-4.  Back to cited text no. 8
Janzel DL, Mathieson JR, Marshall JI, Cooperberg PL, De Rio RH, Golding RH et al., Testicular microlithiasis: Sonographic and clinical features. AJR Am J Roentgenol 1992;158:1703-6.  Back to cited text no. 9
McEniff N, Doherty F, Katz J. Schrager CA, Klauber G. Yolk sac tumour of the testis discovered on a routine annual sonogram in a boy microlithiasis. AJR Am J Roentgenol 1995;164:971-92.  Back to cited text no. 10
David S, editor. Textbook of Radiology and Imaging. 7th ed., Vol. 11 Elsevier Publisher, United Kingdom, 2002. p. 1033.  Back to cited text no. 11
Flush DP, Kliewer MA, Madden IF. Testicular microlithiasis and sequent development of metastatic germ cell tumour. ARJ 1996;167:889-90.  Back to cited text no. 12


  [Figure 1], [Figure 2]


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