Segmental Testicular Infarction in the Setting of Heroin Use.

Segmental testicular infarction (STI) is a rarely documented cause of acute scrotal pain likely resulting from localized ischemia of testicular tissue. It is most often commonly associated with torsion, infection, trauma, or hypercoagulable states, though idiopathic cases can occur. Substance use has been sparsely reported as a potential contributing factor. In this case report, we present a case of STI in a patient with recent heroin use, highlighting a possible association and emphasizing the importance of imaging in acute testicular pain. A 48-year-old male with a history of polysubstance use presented with progressively worsening right testicular pain. He reported heroin use four days prior and described a history of intermittent, self-resolving testicular pain over several years. Physical examination revealed a heterogeneous right testicle with focal firmness. Laboratory evaluation, including tumor markers, was unremarkable. Doppler ultrasound demonstrated heterogeneous echotexture and reduced vascular flow in the right testicle. MRI of the pelvis showed hypoenhancement and absent diffusion signal consistent with segmental infarction. The patient was managed conservatively with analgesia and instructions for outpatient urology follow-up. STI may present with variable and chronic symptoms, making diagnosis difficult. This case illustrates heroin use as a possible contributing factor, possibly through vasoconstriction or prothrombotic effects, leading to compromised testicular perfusion. Clinicians should consider STI in patients with atypical or chronic testicular pain, particularly in the setting of substance use. Early imaging is critical for guiding management and avoiding unnecessary surgical intervention.