questions 2

Varicocele

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Topic updated on 07/31/17 10:14am

Overview
 

 
Snapshot
  • A 34-year-old man presents to the fertility clinic for evaluation of infertility. His him and his wife have been trying to have children for 2 years. His wife was recently evaluated and found to be normal and healthy. The patient denies any pain in his testicular region. However, he reports occasional feelings of heaviness in his scrotum. On physical exam, his scrotum looks distended. Valsalva maneuvers result in a "bag of worm"-like finding upon palpation of the testicle.
Introduction
  • Clinical definition
    • varicose veins in the scrotum
  • Epidemiology
    • incidence
      • 15% in adult men
      • 8-20% in adolescent boys
      • most common cause of scrotal enlargement in adult males
    • demographics
      • around puberty in adolescents
    • location
      • most often on left side
        • due to increased resistance from left gonadal vein draining into left renal vein
  • Etiology
    • primary varicocele
      • venous reflux
    • secondary varicocele
      • renal cell carcinoma causing compression to the veins
      • retroperitoneal tumor
      • portal hypertension 
  • Pathogenesis
    • increased venous pressure causing dilated veins in the pampiniform plexus
Presentation
  • Symptoms
    • primary symptoms
      • dull ache in scrotum
      • feeling of heaviness in scrotum
      • may be asymptomatic
      • atrophy or hypotrophy
      • infertility
  • Physical exam
    • standing or valsalva maneuver
      • distension on inspection
      • “bag of worms” on palpation
    • illumination test with light
      • scrotum does not transilluminate
Imaging
  • Ultrasound with doppler
    • indications
      • if varicocele is suspected but physical exam is inconclusive
    • findings
      • dilatation of vessels of pampiniform plexus > 2 mm
      • reflux in pampiniform plexus
    • sensitivity and specificity
      • both 100%
  • CT abdomen with contrast
    • indications
      • right-sided or bilateral varicoceles may indicate IVC obstruction
    • findings
      • IVC thrombosis or compression
Studies
  • Semen analysis
    • to test for complications of varicocele (e.g., infertility)
Differential
  • Hydrocele      
    • positive transillumination test
  • Testicular torsion
    • abnormal cremasteric reflex
Treatment
  • Conservative
    • monitor with annual exams 
      • indications
        • asymptomatic patients
        • no testicular hypotrophy
  • Operative
    • surgical ligation or embolization
      • indications
        • pain
        • infertility
        • delayed growth of testes
      • outcomes
        • in terms of fertility, 40% of couples recover with successful pregnancy
Complications
  • Infertility due to increased temperature of scrotum
  • Testicular atrophy


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Qbank (1 Questions)

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(M3.RL.6) A 28-year-old male presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count with 'poor quality' sperm. Examination reveals a scrotum that, on the right side only, is enlarged and feels like a 'bag of worms' on palpation. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown in Figure A. Which of the following is the best next step in the management or evaluation of this patient's presentation? Topic Review Topic
FIGURES: A          

1. Observation with no further testing or management
2. MRI pelvis
3. CT abdomen
4. Embolization
5. Surgical repair

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