This patient's presentation 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.
Varicocele is a dilation of the pampiniform venous plexus and spermatic veins. It is relatively common, occurring in approximately 10% of all males and is associated with infertility in some cases. 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, suspicion is raised for a force restricting return blood flow from the testicle to the IVC. Potential causes may include an IVC thrombus or abdominal mass compressing the IVC.
Crawford et al. discusses the evaluation of painful scrotal masses. Hydrocele, varicocele, and scrotal skin lesions can be managed nonemergently; however, the pain associated with varicocele needs to be differentiated from testicular torsion, which must be repaired within 6 hours. Testicular torsion is characterized by acute-onset severe testicular pain with nausea/vomiting, an elevated testicle, and an absent cremasteric reflex.
Solish et al. discuss a case study of a male presenting with bilateral varicoceles secondary to IVC thrombosis. Ultrasound was obtained initially to confirm the diagnosis of bilateral varicocele. A follow-up CT abdomen/pelvis with contrast revealed an occlusive thrombus in the IVC with compensatory enlargement of the azygous/hemiazygous system.
Figure A shows an ultrasound and color Doppler study of a patient with varicocele; note the numerous anechoic tubes with bidirectional flow. Illustration A depicts the anatomy of the left and right testicular veins. Note that the left testicular vein drains into the left renal vein; however, the right testicular vein drains directly into the IVC.
Answer 1: The signs in this patient's presentation suggestive of IVC obstruction warrant obtaining a CT abdomen.
Answer 2: MRI of the pelvis does not have a role in evaluating varicocele or in evaluation of IVC obstruction.
Answers 4 & 5: Embolization and surgical repair of varicocele are viable treatment options when indicated (such as cases where varicocele may be contributing to male infertility); however, the signs in this patient's presentation that are suggestive of possible IVC obstruction warrant further evaluation with a CT abdomen.
Crawford P, Crop JA. Evaluation of scrotal masses. Am Fam Physician. 2014 May 1;89(9):723-7.
PMID:24784335 (Link to Abstract)
Solish AF, Germaine P. Bilateral intratesticular and extratesticular varicoceles secondary to extensive inferior vena cava thrombosis. J Ultrasound Med. 2010 Jan;29(1):141-3.
PMID:20040788 (Link to Abstract)