Testicular Compartment Syndrome Post Bilateral Microdissection Testicular Sperm Extraction: A Case Report and Review of the Current Literature.

Background: Testicular compartment syndrome (TCS) is a rare phenomenon with around 14 cases reported in the literature. It occurs when extraluminal compression or increased venous resistance leads to raised intratesticular pressure. The fibrous tunica albuginea covering the testes does not distend, meaning the pressure is not relieved and compartment syndrome can develop. The ensuing reduction in perfusion and subsequent reperfusion injury can compromise testicular viability, making prompt identification and early surgical intervention essential in optimising outcomes. Case Presentation: A 41-year-old male presented to the emergency department with acute severe bilateral testicular pain 1 day after bilateral microdissection testicular sperm extraction (mTESE) for primary infertility and azoospermia. He reported a gradual onset of bilateral testicular pain throughout the day accompanied by oozing and bleeding from the surgical wound. The pain escalated with time, and both testicles were exquisitely tender on palpation. Ultrasonography (US) demonstrated diffuse scrotal sac thickening, heterogenous testicles with hyperaemia on Doppler flow and bilateral hyperaemic enlargement of both epididymi. Thus, an emergency scrotal exploration was performed with evacuation of a left intratesticular haematoma and a right peritesticular haematoma. This restored perfusion to both testes and the patient had an uneventful postoperative course. A follow-up US after 6 weeks revealed both testicles had a reduction in volume and reduced blood flow. Conclusion: TCS is a previously undocumented complication of mTESE that should be considered in any patient presenting with pain out of proportion to clinical findings. Although the diagnosis is primarily clinical, US features, such as initial hyperaemia progressing to reduced blood flow, can support the diagnosis. Early surgical intervention to decompress the testis by incising the tunica layers is critical to reduce intratesticular pressure, restore perfusion and preserve testicular viability.