A 66-year-old man comes to the office due to 3 months of scrotal discomfort. He reports heaviness and a dull ache in the left scrotal area that is worse toward the end of the day. He has no fever, dysuria, hematuria, or penile discharge. The patient has a history of hypertension and takes amlodipine. He had a vasectomy 20 years ago. He lives with his wife and has 2 grown children.
On examination, the abdomen is soft and nontender without organomegaly. Examination in the standing position shows a palpable, soft, irregular, nontender mass above the left testis that disappears in the supine position. There is no skin redness, groin bulge, or transillumination. Both testes are normal in size and without tenderness.
Which of the following is the most appropriate next step in management of this patient?

Question

A 66-year-old man comes to the office due to 3 months of scrotal discomfort.  He reports heaviness and a dull ache in the left scrotal area that is worse toward the end of the day.  He has no fever, dysuria, hematuria, or penile discharge.  The patient has a history of hypertension and takes amlodipine.  He had a vasectomy 20 years ago.  He lives with his wife and has 2 grown children.
On examination, the abdomen is soft and nontender without organomegaly.  Examination in the standing position shows a palpable, soft, irregular, nontender mass above the left testis that disappears in the supine position.  There is no skin redness, groin bulge, or transillumination.  Both testes are normal in size and without tenderness.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9871_1d58_853d_ef4660d57c93_MD0002_00 This patient's presentation suggests a varicocele, which is due to tortuous dilation of the pampiniform plexus of veins surrounding the spermatic cord and testis in the scrotum. Varicoceles occur in up to 20% of men (usually age 15-25); they are usually left sided, but up to 30% can be bilateral. The left spermatic (gonadal) vein enters the left renal vein at a right angle. The aorta and superior mesenteric artery can compress the left renal vein and increase intravascular pressure within the left renal and gonadal veins. This can cause incompetence of the valves, retrograde blood flow, and venous dilation. varicocele Patients can be asymptomatic or develop a dull ache with standing. Examination usually shows a soft mass that is enlarged with standing and Valsalva maneuvers but diminishes when supine. Ultrasound can show retrograde venous flow and dilation of pampiniform plexus. Asymptomatic patients do not require treatment. Those with scrotal discomfort usually improve with analgesics (eg, nonsteroidal anti-inflammatory drugs) and/or scrotal support. Potential complications include infertility and testicular atrophy (due to increased scrotal temperature). (Choice A) Annual scrotal ultrasound is not typically recommended for varicoceles. However, this patient may require further imaging if he has persistent symptoms or new testicular findings (eg, solid mass). (Choice B) Because the right gonadal vein empties directly into the inferior vena cava, right-sided varicoceles are rare and can indicate inferior vena cava compression (eg, renal cell carcinoma) or obstruction (eg, thrombus). Sudden onset of left-sided varicocele that does not diminish in the recumbent position may also indicate obstruction. CT imaging is suggested in such cases but is otherwise not necessary. (Choices D and E) Serial semen analysis is usually reserved for men who desire fertility. Surgical referral is recommended for younger men with scrotal atrophy or older men who desire fertility. This patient has no scrotal atrophy and has had a vasectomy. Educational objective: Varicoceles are due to tortuous dilation of the pampiniform plexus surrounding the spermatic cord. Asymptomatic patients do not require treatment; those with scrotal discomfort usually improve with analgesics (eg, nonsteroidal anti-inflammatory drugs) and/or scrotal support. __________ References: The varicocele. (http://www.ncbi.nlm.nih.gov/pubmed/24286772) Testicular varicocele: an overview. (http://www.ncbi.nlm.nih.gov/pubmed/19506401)

A 66-Year-Old Man Comes to the Office Due to 3