sarcoidosis is a multisystem granulomatous disease of unknown etiology that affects individuals worldwide , usually involving the lungs and lymph nodes , and is characterized pathologically by the presence of noncaseating granulomas in the affected organs . although almost any organ can be involved , genitourinary involvement with sarcoidosis is very rare . up to now , less than 60 cases of sarcoidosis of the male genitourinary tract , with histological confirmation , have been reported in the english literature . because of its uncommon nature , the treatment of male reproductive tract sarcoidosis is controversial . here , a 42-year - old man presented with intermittent , bilateral testicular pain and swelling of 1 month 's duration , associated with a dry cough for 1 week . dry cough and weight loss had begun 2 years before he visited our clinic , and he had been treated with a high - dose steroid for presumptive diagnosis of sarcoidosis at another hospital for less than a year . the diagnosis had been based on hilar and mediastinal lymphadenopathy found in chest computed tomography ( ct ) , and chronic granulomatous inflammatory reaction in a bronchial mucosal biopsy . he had no complaints ever since , and he was under treatment with a low - dose steroid during this interval . he reported absence of symptoms such as dyspnea , chest discomfort , sputum production , night sweats , weight loss , skin rashes and dysuria , as well as other symptoms . additionally , he was infertile for more than 10 years , and in vitro fertilization ( ivf ) attempts were not successful . his temperature was 37.3c ; heart rate , 80 to 90 beats / min ; blood pressure , 140/92 mm hg ; and respiratory rate , 18 to 20 breaths / min . physical examination revealed no lymphadenopathy ; examination of head and neck , respiratory , cardiovascular systems and abdomen revealed no abnormality as well . the genitourinary examination was significant for firm and nontender testicular masses , especially on the right side , and a firm enlarged epididymis . laboratory investigations for cbc differential count , erythrocyte sedimentation rate , c - reactive protein , electrolytes , serum calcium and phosphorus levels , liver function , renal function , arterial blood gases , urine studies , urine calcium and urine protein , rheumatoid factor , antinuclear antibodies , anti - neutrophil cytoplasmic antibodies ( c.anca and p.anca ) , complement levels ( c3 , c4 , ch50 ) , adenosine deaminase , and serological studies for brucellosis all revealed results that were negative or within normal limits . serum angiotensin converting enzyme ( ace ) levels determined on several occasions in the past 3 years were on the higher side of the normal range . tuberculosis skin test , tests for hiv , and serology findings with regard to hepatitis c and b were negative . serum alpha fetoprotein and beta  human chorionic gonadotropin levels were also within normal limits . semen analysis in the past 10 years revealed no abnormality ; however , he gradually became azoospermic during the last 3 years . chest computed tomography ( ct ) demonstrated small mediastinal ( right paratracheal and hilar ) lymph nodes [ figure 1 ] . ct scan of the chest prior to visiting our clinic , showing small mediastinal ( right paratracheal and hilar ) lymph nodes abdominopelvic and scrotal ultrasonography revealed scrotal thickening , a large epididymis with heterogeneous echo , and several hypoecho testicular masses ( 3 - 4 mm ) [ figure 2 ] but was otherwise normal . ultrasonography of the right testis , showing two hypoecho testicular masses pulmonary function tests disclosed a normal pattern , without any reduction in the diffusing capacity for carbon monoxide . bronchoalveolar lavage ( bal ) demonstrated a reduced number of cd8 cells , as well as an elevated cd4-to - cd8 ratio . direct smear and culture of bronchial washing samples was negative for acid - fast bacilli , fungi or any pathogenic bacteria . sarcoidosis presents in a variety of ways , but the disease usually localizes to the chest in 80% to 90% of patients , characterized by bilateral , hilar lymphadenopathy on chest radiographs , which are precise , evocative findings for the diagnosis . although noncaseating granulomas on biopsy are very suggestive , the diagnosis is ultimately one of ruling out other conditions . the genitourinary tract is involved in sarcoidosis in 0.2% of the clinically diagnosed cases and in 5% of the cases found at autopsy . it is 10 times more frequent in black men and has a greater prevalence in the southeastern united states . manifestations of genitourinary sarcoidosis include usually painless , unilateral , nodular and diffuse testicular masses ; acute epididymo - orchitis , and renal disorders with nephrocalcinosis . following the identification of a scrotal mass , differential diagnosis includes tuberculosis , sperm granulomas , cysts , fungal diseases and , the most notable , testicular cancer . testicular involvement of sarcoidosis is extremely rare . in order of decreasing incidence of genital sarcoidosis , an excessively high incidence of testicular cancer ( generally seminoma ) in a number of patients with simultaneous sarcoidosis has been reported . however , metastatic lesions that are radiographically and pathologically identical to sarcoidosis have been reported in patients with resected testicular cancer after a disease - free interval of 8 years , as well as the absence of recurrence at the primary site . even though fertility - related sequels of genitourinary sarcoidosis have not been studied so far , azoospermia and hypogonadism may be caused by fibrosis and occlusion of the epididymal duct . steroid therapy has been reported recently to be beneficial in raising sperm counts ( and to some extent , ductal occlusion ) . based on the marked relationship between testicular cancer and sarcoidosis , orchiectomy is recommended , even if evidence of sarcoidosis in other organs is present . by contrast , others consider immediate orchiectomy as being quite aggressive because of several factors associated with a benign diagnosis , as well as the involvement of the epididymis or vas deferens and bilateral testicular involvement . if the malignant diagnosis is established by exploration and intraoperative ultrasound - guided biopsy , orchiectomy is performed in cases of diffuse involvement of a testis . if the diagnosis is not established unequivocally , immunosuppressive agents ( frequently steroids ) will resolve the inflammation in patients who wish to salvage their fertility ; and in those with severely advanced disease , after careful consideration . a new approach has been proposed recently , based on the absence of evidence for malignant transformation in pathologically confirmed benign diagnosed testicular sarcoidosis , and it involves the open exploration of both testes , with resection of the largest lesion ( on the right tunica ) . in this technique , nevertheless , careful follow - up may be preferred to medication or surgery in certain clinical settings . in our case , because of the patient 's desire for maintaining his fertility and the absence of evidence of malignancy , the patient underwent unilateral testicular and epididymal biopsy . the biopsy revealed fibrotic tissue with a non - necrotizing granuloma made up of epithelioid and giant cells and focal lymphatic infiltration [ figures 3 and 4 ] . after the administration of steroids ( prednisolone , 30 mg / d ) , testicular masses vanished , and the patient was followed up with ultrasonography . the azoospermia recovered , and zygote intra - fallopian transfer ( zift ) was performed . the patient has not had a recurrence of any sarcoidosis lesions during the 2-year follow - up period . ( a - b ) intraoperative ultrasound - guided biopsy ; showing fibrotic tissue with a non - necrotizing granuloma made up of epithelioid and giant cells and focal lymphatic infiltration ( magnification : 40 and 100 respectively ) in conclusion , although genitourinary sarcoidosis is rare , it must be taken into consideration , in patients with confirmed sarcoidosis , since the diagnosis can prevent unnecessary orchiectomies .
genitourinary involvement with sarcoidosis is very rare . the objective of this report was to present a case of a patient with testicular swelling . 
 the patient was an infertile 42-year - old man with bilateral testicular swelling . 
 semen analysis in the past 10 years revealed no abnormality ; however , gradually he became azoospermic in 3 years . 
 a diagnosis of sarcoidosis made on the basis of hilar and mediastinal lymphadenopathy in chest ct scan was confirmed through testicular and epididymal biopsy . 
 testicular masses vanished after administering steroids , and azoospermia recovered . to conclude , 
 although genitourinary sarcoidosis is rare , it must be kept in mind in patients with confirmed sarcoidosis .