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Varicoceles
Case: 14yo M in PCP office for WCC and evaluation of a “groin problem.” He notes that in the last few months it seems like his testes are different sizes. He denies pain, though sometimes he has some discomfort, mostly on the left side, but otherwise it hasn’t bothered him. He thinks he feels a lump. He’s worried about it because he just read about Lance Armstrong and wants to make sure he doesn’t have testicular cancer. No other complaints, ROS negative. On exam, no erythema, induration or tenderness of the scrotum. Left testis notably smaller than right testis. Left side of scrotum notable for “bag of worms” superior to the testicle, which becomes notably distended on Valsalva maneuver.
Does this patient need a surgical consult? What would make you worried about something more serious?
Differential Diagnosis of testicular mass:
Must-not-miss: Testicular torsion (usually acute, assoc. with pain) Epididymitis (assoc with urethral discharge, erythema, and fever) Acute Orchitis (testicular pain, nausea and vomiting, 3-4 days after mumps parotitis) Inguinal hernia Testicular cancer (painless mass, avg age at diagnosis: 32)
Benign causes of testicular mass: Hydrocele (typically in infancy, resolves by 1yr, if new, look for other pathology) Varicocele (“bag of worms”, left sided) Spermatocele (painless cystic mass)
Varicoceles are caused by dilation of the testicular veins. In one recent study, 98.5% of repaired varicoceles were on the left side, 1.5% were bilateral. None of the patients in the study had an isolated right-sided varicocele. Varicoceles have been cited as the most common surgically correctable cause of infertility in males. Incidence 1. Approximately 15 % of males between 10-25 years of age have varicoceles. 2. Rare before 9 years of age and the start of puberty. 3. Of men evaluated for infertility, 30% have varicoceles 4. 15% of males with varicoceles seek medical advice concerning infertility Etiology- none proven although linked to the unusual venous drainage system of the left testicle. As veins from the testicle emerge, they form a system of branching vessels that is called the pampiniform plexus. This network allows for cooling of the blood that comes in through the arterial system via a counter-current heat exchange. Hypotheses include:
Diagnosis
a. "bag of worms" b. Asymmetrical scrotal contents c. Enlargement with Valsalva maneuver d. Disappears in supine position e. Measure testicular volume to assess effect of varicocele on testicular growth Management
a. Greater than 2 ml. volume difference of left to right testicle measured by ultrasound b. Bilateral varicoceles c. Large varicoceles associated with discomfort and pain. 4. Prior to surgery, discuss psychological aspects of varicoceles and associated issues with patient References
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