Review Question - QID 102722

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Varicocele Presentation Symptoms QID: 102722 (M3.RL.16.4)

QID 102722 (Type "102722" in App Search)

A 14-year-old male patient, with no past medical history, presents to the clinic with 2-months of pain in his lower abdomen. Upon further questioning he states that the pain is a dull and a 2/10 in severity that worsens the longer he stands. The pain goes away when he lies down. The patient is not sexually active and has had no recent trauma. His vital signs are all within normal limits. On physical exam you note a palpable and slightly tender mass on his left testicle. An ultrasound of the mass is performed and can be seen in Figure A. What is a potential seqelae of this issue if left untreated?

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Testicular necrosis

27%

3/11

Testicular abscess

0/11

Testicular atrophy

36%

4/11

Intestinal necrosis

18%

2/11

Testicular rupture

18%

2/11

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This patient has a varicocele, which is a dilation of the pampiniform venous plexus in the scrotum. Prolonged, unresolved varicocele can result in testicular atrophy.

Varicocele is extremely common in adolescent and adult men (~15%). It commonly occurs on the left side due to the anatomical angle affecting drainage of the left testicular vein into the left renal vein. Varicocele is associated with decreased testicular volume, abnormal semen analysis, and potentially decreased fertility. In fact, ~40% of men with infertility have a varicocele. Indications for varicocelectomy are unclear but may be recommended in patients who have pain, decreased testicular volume, or infertility.

Crawford et al. discuss diagnoses of varicocele. A varicocele feels like a bag of worms upon palpation and increases in size upon straining or Valsava maneuver. It does not transilluminate with a penlight. Varicoceles are often painless but may be uncomfortable after prolonged standing. Adolescence is the most common time period of onset of varicoceles.

Kolon discusses evaluation and management of varicoceles. Varicocele assessment includes grade of mass, testicular volume, endocrine evaluation, semen analysis and ultrasound. Grade (I-III) of a varicocele is as follows: I-palpable when standing and performing Valsava, II-Palpable without Valsava, III-Easily visible. The grade of the varicocele has not been associated with changes in testicular health. Decreased testicular volume, is associated with decreased spermatogenic potential and is an indication for surgery.

Figure A demonstrates a dilated pampiniform plexus, indicative of varicocele.

Incorrect Answers:
Answer 1: Testicular necrosis can result from untreated torsion of the spermatic cord.
Answer 2: Testicular abscess can result when untreated epididymitis spreads into testicular tissue.
Answer 4: Intestinal necrosis can result from an inguinal hernia, which also may present as a mass in the scrotal sac.
Answer 5: Testicular rupture can result from trauma.