Left testicular venous infarction secondary to large spontaneous retroperitoneal haematoma compressing left testicular vein: a case report

Background

Spontaneous retroperitoneal haematoma (RPH) is a rare but recognised condition seen in patients with bleeding disorders, on anticoagulation therapies or haemodialysis.1 Documented complications of RPH include local mass effects such as femoral neuropathy, abdominal compartment syndrome, obstructive uropathy and persistent pain, as well as systemic effects secondary to hypovolaemia.2 While compression of the testicular vein causing thrombosis, venous ischaemia and infarction of the testis is also a potential complication due to the anatomical course of this vessel within the retroperitoneal space, it is yet to be reported.

We present a case of a large spontaneous left-sided RPH in a patient with therapeutic anticoagulation for underlying homozygous factor V Leiden, causing compression on the left testicular vein. This resulted in extensive venous thrombus and subsequent left testicular venous infarct, causing severe pain requiring emergent surgery for scrotal exploration and left orchidectomy. To our knowledge, this is the first case report documenting testicular venous infarct as a complication of RPH in the literature.

Case presentation

A man in his early 50s presented to our emergency department with a 4-day history of severe abdominal pain and constipation. He had no nausea or vomiting and there were no urinary symptoms. There was no history of trauma. His medical history included homozygous factor V Leiden, diagnosed after an unprovoked episode of deep vein thrombosis and pulmonary embolism 6 years prior to this admission. The patient’s usual warfarin dose was 10 mg daily, with a therapeutic target international normalised ratio (INR) between 2 and 3; however, he had been non-compliant with regular INR monitoring. Clinical examination revealed a soft and distended abdomen, with tenderness in the left upper and lower quadrants, as well as positive Grey-Turner’s and Cullen’s signs. The patient was haemodynamically stable.

His admission blood results revealed abnormal blood parameters with a low haemoglobin count of 79 g/L, mildly elevated white cell count of 12.23×1o⁹/L, elevated platelets of 300×1o⁹/L, significantly raised INR and lactate of 9.0 and 3.8 mmol/L, respectively. An urgent CT with intravenous contrast of the abdomen–pelvis was performed, which revealed a large 24 cm left retroperitoneal haematoma with multiple foci of contrast extravasation indicating active bleeding (figure 1). A haematological opinion was sought to promptly reverse the effect of warfarin by administration of 1 unit of fresh frozen plasma, intravenous vitamin K and prothrombin factor complex (Prothrombinex). The patient was also transfused 1 unit of packed red cells with an appropriate resultant haemoglobin increment. A CT angiogram of the abdomen–pelvis was performed after resuscitation and correction of coagulopathy which showed a stable haematoma without further evidence of active bleeding. The decision was subsequently made by the surgical and interventional radiology team to hold off an initially planned angioembolisation at this point of time. After 24 hours of close monitoring in the intensive care unit, the patient was discharged to the ward for ongoing expectant management of the RPH, with haematology input for recommendation of anticoagulation restart.

On day 4 of the admission, the patient reported a 3-day history of scrotal pain and swelling to the medical team for the first time during his inpatient stay. Clinical examination revealed a diffusely enlarged and tender scrotum with widespread ecchymoses, worse on the left side compared with the right. An urgent testicular ultrasound was performed, which showed infarction of the left testis but was unable to clearly rule out testicular torsion (figure 2). The INR was 1.6 at this stage, compared with 9.0 on admission. Despite the elevated INR, the decision was made to proceed for emergency scrotal exploration with the urology team with the hope, although unlikely, for testicular salvage. Intraoperatively though, the scrotal skin was grossly oedematous, and the left testis was found to be diffusely congested and no longer viable. The left spermatic vein and venules were completely thrombosed with extensive clots (figure 3); however, the left testicular artery remained intact. Consequently, a left orchidectomy was performed. The right hemiscrotum was also explored with normal findings.

The patient recovered well from the surgical perspective; however, his inpatient stay was complicated by hospital-acquired pneumonia and postoperative pulmonary embolism requiring intravenous antibiotics and high-flow nasal prongs. A prophylactic dose of enoxaparin was administered immediately following surgery, and therapeutic anticoagulation was recommenced on day 3 postoperatively with enoxaparin 1 mg/kg two times per day, followed by transition to oral anticoagulant (rivaroxaban) on discharge.

Outcome and follow-up

The patient was followed up in the general surgical and urology outpatient clinic 3 weeks after his initial acute presentation with an ultrasound of the abdomen showing a small reduction in size of the left RPH. The scrotal surgical wound had healed well and the patient reported that he had returned to his normal daily activities without any further issues.