QuestionSBA
QuestionChoice
This is infection/inflammation of the testis and epididymis. It is often caused by sexually transmitted infections such as chlamydia but also caused by viral causes such as mumps. Patients report a tender generalised swelling and may have other associated features of infection (temperature, dysuria, penile discharge). Treatment is with antibiotics depending on the likely source (NB if sexually transmitted infection deemed likely source then contact tracing and treatment of partners should be initiated)
32725
c
Epididimo-orchitis
QuestionChoice
This is unlikely but should be carefully considered in the differential as testicular tumours are the commonest malignancy in this age demographic. They usually present as a painless, firm lump in the testes found after trauma/infection and may have a secondary hydrocoele
32726
d
Testicular tumour
QuestionChoice
A varicocele is caused by dilated veins of the pampiniform plexus and often may only be present on standing. 90% occur on the left. They are associated with subfertility, but surgical repair appears to have little effect on subsequent pregnancy rates. Treatment is with scrotal support or surgery (varicocelectomy)/embolisation
32723
a
Varicocoele
QuestionChoice
This would be in the differential and are caused by fluid within the tunica vaginalis; however, the description and the lack of transillumination make varicocoele more likely
32724
b
Hydrocoele
QuestionChoice
This presents as a painless nodule at the head of the epididymis adjacent to the inferior pole of the testis and will transilluminate. They may contain clear or milky (spermatocele) fluid
32727
e
Epididymal cyst
QuestionComment
how dare you not say bag of worms
23325
User
subscriber
lil' aneurysm
QuestionComment
WHERE BAG OF WORMS 
60140
User
subscriber
Transplant Tazocin
QuestionComment
"lump" is not a good description of a varicocele...
62254
User
subscriber
Sydney Sweeney
Concept
Chapter
# Summary

Varicocele is defined as an enlargement of the scrotal veins, often asymptomatic but may cause a sense of aching or heaviness within the scrotum. They can also contribute to male infertility, accounting for 25-40% of such cases. Diagnostic investigations include physical examination, Doppler ultrasound, and possibly hormonal assays. Management is dependent on symptom severity and includes options such as watchful waiting, embolization, and surgery.

# Definition

Varicocele is a condition characterized by an enlargement of the veins within the scrotum, similar in nature to varicose veins that can occur elsewhere in the body.

# Epidemiology

While varicocele is relatively common, affecting around 15-20% of all men, its prevalence significantly increases in the infertile population, reaching up to 40%. It typically develops in adolescence and early adulthood.

# Aetiology

Varicoceles develop due to faulty valves within the spermatic cord veins, causing blood to pool and enlarge these veins. Although the exact mechanism that leads to male infertility is unclear, it's hypothesized that increased testicular temperature and oxidative stress may play a role. In a minority of cases, left-sided varicoceles can be caused by compression of the gonadal vein, such as from a renal cell carcinoma.

# Signs and Symptoms

While many varicoceles are asymptomatic, when symptoms do present, they may include:

-   Aching or heavy feeling in the scrotum
-   Visibly enlarged or twisted veins in the scrotum, often described as a "bag of worms"
-   Testicular atrophy
-   Impaired fertility

# Differential Diagnosis

The primary conditions to consider when diagnosing varicocele include:

-   Epididymitis: Key signs and symptoms include scrotal pain and swelling, potentially with fever and urinary symptoms.
-   Testicular torsion: This presents with sudden severe testicular pain, swelling, nausea, and vomiting.
-   Inguinal hernia: Symptoms typically include a visible bulge in the groin region or scrotum, pain, and possible bowel or bladder symptoms.
-   Hydrocele: This condition usually causes painless scrotal swelling.

# Investigations

The following investigations can aid in diagnosing varicocele:

-   Physical examination: Varicoceles can often be identified by palpation of the scrotum, especially while standing or during a Valsalva maneuver.
-   Doppler ultrasound: This imaging modality can identify the enlarged veins and assess for retrograde blood flow, confirming the diagnosis.
-   Hormonal assays: In cases where infertility is suspected, evaluation of testosterone, FSH, LH, and semen analysis can be useful.

# Management

The management strategy for a varicocele depends largely on the symptom severity and patient’s fertility desires. Options include:

-   Watchful waiting: For asymptomatic varicoceles or those not causing fertility problems.
-   Embolization: This minimally invasive procedure involves blocking the blood flow to the enlarged veins.
-   Surgery: Varicocele repair surgery can be performed through open surgery, laparoscopically, or with robotic assistance.
1594
2005
Varicocele
Topic
22
Urology
6545
A varicocele, often present only when standing and typically occurring on the left, is caused by dilated veins of the pampiniform plexus, associated with subfertility, and treated with scrotal support or surgery/embolization.
A 34-year-old male presents to the sexual health clinic concerned about a lump he has found in his left testicle. He is sexually active but does not complain of any penile discharge or any urinary symptoms. On examination, there is a soft fleshy lump that is separate from the spermatic cord. It is only palpable when the patient is standing and not when lying down. It does not transilluminate.

What is the most likely diagnosis?
a