This patient’s presentation is consistent with a varicocele. Varicocele commonly results from blockage of blood drainage from the pampiniform plexus in the scrotum, resulting in engorgement of this venous network and the resulting classic appearance of the scrotum as a “bag of worms.”
Left-sided varicocele is more common due to the drainage of the left testicular vein by the left renal vein, which is susceptible to compression. This differs from the drainage of the right scrotum, where the right testicular vein drains directly into the inferior vena cava. Varicocele may also arise from idiopathic failure of valves in the testicular vein and pampiniform plexus.
Boyd describes the presentation and management of varicoceles. 15% of the adult (post-pubertal) male population develops varicoceles. It is a presentation commonly associated with male infertility, with approximately one-third of men seen in fertility clinics having this lesion. Semen samples in varicocele patients may show decreased sperm counts, reduced sperm motility, and immature cellular morphology. Treatment is usually surgical; however, percutaneous approaches may be appropriate in certain situations.
Shiraishi et al. review the diagnosis of varicocele and associated treatment benefits in the setting of male infertility. Surgical treatment in the form of a varicocelectomy has been shown to improve fertility with demonstrated increases in pregnancy and live-birth rates. Physical examination, scrotal ultrasound with color doppler, and scrotal temperature measurements (a surrogate marker for testicular oxidative stress) can all be used to aid in establishing a diagnosis and management strategy for a varicocele.
Figure A is a clinical image of a varicocele. Illustration A depict a left-sided varicocele.
Answer 2: This mechanism is consistent with a hydrocele, which typically presents with scrotal enlargement and can be differentiated via positive transillumination test.
Answer 3: This answer choice describes a case of infection of the epididymis, which presents with unilateral scrotal pain along with scrotal swelling and tenderness.
Answer 4: Cryptorchidism should present as a completely absent testis or improper caudal location of the testis on physical exam of the scrotum and is not associated with the “bag of worms” appearance of the scrotum.
Answer 5: This mechanism is consistent with testicular torsion, which manifests with acute onset of severe testicular pain and a tender/swollen testis.
Boyd AS. Varicoceles and male infertility. Am Fam Physician. 1988 Feb;37(2):252-8.
PMID:3278567 (Link to Abstract)
Shiraishi K, Matsuyama H, Takihara H. Pathophysiology of varicocele in male infertility in the era of assisted reproductive technology. Int J Urol. 2012 Jun;19(6):538-50.
PMID:22417329 (Link to Abstract)
USMLE World Step 1 QBank Question #1805. Copyright © USMLEWorld, LLC 2012