Evaluation of nonacute scrotal pathology in adult men

VARICOCELE  A varicocele is caused by dilatation of the pampiniform plexus of spermatic veins

It is present in 15 to 20 percent of post-pubertal males, occurring in the usually left hemiscrotum in the vast majority of cases. The venous complex in the scrotum dilates and produces anything from minimal fullness on Valsalva maneuver to a large soft scrotal mass ("bag of worms") that decompresses and disappears in the recumbent position

Grade Size Clinical description 1 Small 2 Moderate 3 Large Grading of varicoceles Grade Size Clinical description 1 Small Palpable only with valsalva maneuver 2 Moderate Nonvisible on inspection, but palpable upon standing 3 Large Visible on gross inspection

Bilateral varicoceles occur in 33 percent of patients. Unilateral right varicoceles are very rare and should alert the clinician to possible underlying pathology causing inferior vena caval obstruction (renal cell carcinoma with IVC thrombus, right renal vein thrombosis with clot propagation down the IVC, etc), since the right gonadal vein directly empties into the IVC.

Symptoms Varicoceles may be asymptomatic or present with: Dull, aching, usually left scrotal pain, typically noticeable when standing and relieved by recumbency Testicular atrophy, believed to be secondary to loss of germ cell mass by induction of apoptosis (programmed cell death) initiated by the associated slightly increased scrotal temperature Decreased fertility

A large number of infertile men are found to have a varicocele on examination On the other hand, men with varicoceles may have normal semen parameters and normal fertility.

Treatment is indicated for boys who demonstrate retarded growth of the affected (usually, left) testis and in young men who develop testicular atrophy. There are data to suggest that catch-up growth of the atrophic testis is possible in some cases after surgery and that return of testicular size postoperatively directly correlates with normal fertility potential

in the younger infertile man with a clinically apparent varicocele, it seems reasonable to recommend surgical ligation Subclinical varicoceles are often discovered as part of an infertility evaluation by demonstrating retrograde flow to the scrotum by Color Doppler ultrasonography. The role of surgical ligation for subclinical varicoceles associated with subfertility is not clear.

Epididymal cysts and spermatoceles Epididymal cysts are usually palpated in the head (caput) of the epididymis and are generally asymptomatic They occur with increased frequency in male offspring of mothers who used diethylstilbestrol during pregnancy. In addition, epididymal cystadenomas are seen in more than one-half of patients with Von Hippel-Lindau disease and are often bilateral

These are usually not mistaken for other scrotal pathology, and they can be diagnosed by scrotal ultrasonography if the clinical examination is equivocal. No treatment is required.

The distinction between a spermatocele and an epididymal cyst is mainly one of size; epididymal cystic masses that are larger than 2 cm are called spermatoceles. Spermatoceles are always located superior to the testis and are palpated as distinct from the testis, which differentiates them from hydroceles. Spermatoceles generally range in size from 2 to 5 cm and rarely cause symptoms. Occasional patients require surgical excision for chronic pain related to a spermatocele

Hydroceles A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, the investing layer that directly surrounds the testis and spermatic cord

Symptoms of pain and disability generally increase with the size of the mass. Hydrocele fluid in the scrotal sac transilluminates well, which differentiates the process from a possible hematocele, hernia, or solid mass. A scrotal ultrasound should be considered if the diagnosis is in question since a reactive hydrocele can occur in the presence of a testicular neoplasm or with acute inflammatory scrotal conditions.

Idiopathic hydroceles usually arise over a long period of time and are the most common type of hydrocele. Inflammatory conditions of the scrotal contents (epididymitis, torsion, appendiceal torsion) can produce an acute reactive hydrocele, which often resolves with treatment of the underlying condition.

Thus, treatment is necessary only patients who are symptomatic (pain, pressure) or for the rare situation when scrotal skin integrity is compromised from chronic irritation.

Hydroceles discovered in infancy are usually "communicating," since they are associated with a patent processus vaginalis, which allows flow of peritoneal fluid into the scrotal sac. They usually disappear in the recumbent position and are often associated with herniation of abdominal contents (indirect hernia) through the processus vaginalis. Surgical repair is advised in these cases.

TESTICULAR CANCER Testicular cancer is relatively rare, but it is the most common solid tumor in men between the ages of 18 and 40. It usually presents as a painless mass discovered by the patient or physician on physical examination, although rapidly growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage and infarction

On examination, intrascrotal malignancies are usually firm, nontender masses that do not transilluminate, although a reactive hydrocele may be evident with transillumination.

Scrotal ultrasound is the initial test of choice to diagnose testicular cancer However, several conditions may mimic neoplasia on ultrasound, including inflammation, hematoma, infarct, fibrosis, and tubular ectasia. In cases in which the ultrasound is inconclusive, MRI may help differentiate benign from malignant lesions

Any patient suspected of having a testis cancer should also have blood levels of alpha fetoprotein (AFP) and the beta subunit of human chorionic gonadotropin (beta-hCG) measured.