Review Question - QID 102724

This patient's presentation (low sperm count and the 'bag of worms' finding on the testicular exam) is consistent with a varicocele. Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine are signs suggestive of inferior vena cava (IVC) obstruction and warrant further investigation with a CT scan of the abdomen and pelvis.

Varicocele is a dilation of the pampiniform venous plexus and spermatic veins. It is relatively common, occurring in approximately 10% of all men and is associated with infertility. Over 90% of varicoceles are left-sided, likely secondary to the comparable increased length of the left testicular vein and associated increased venous pressures. In contrast, the right testicular vein is shorter, making varicocele less likely due to lower venous pressures; therefore, when a right-sided varicocele is identified, the suspicion is raised for a force restricting return blood flow from the testicle to the IVC such as a compressive mass or malignancy. Potential causes may include an IVC thrombus or abdominal mass compressing the IVC. Prior to any further direct treatment of the varicocele, it is important to assess the patient with a CT abdomen and pelvis searching for a possible compressive mass.

Figure A shows an ultrasound and color Doppler study of a patient with varicocele. Note the numerous anechoic tubes with bidirectional flow supporting the 'bag of worms' finding on physical exam.

Incorrect Answers:
Answers 2 & 5: Embolization and surgical repair are possible treatment options when indicated (such as cases where varicocele may be contributing to infertility); however, the signs in this patient's presentation that are suggestive of possible IVC obstruction warrant further evaluation with a CT abdomen. It would be inappropriate to directly treat the varicocele without addressing a possible underlying compressive mass.

Answer 3: MRI of the pelvis does not have a role in evaluating varicocele. It may be indicated after a CT scan if there is any need for further characterization of soft tissues or a compressive mass but this is not a typical step in the workup.

Answer 4: Observation is inappropriate as this patient needs to have a possible compressive mass ruled out and would need urology referral to treat his underlying infertility.

Bullet Summary:
Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine warrant a CT scan to rule out inferior vena cava (IVC) obstruction.