A 22-year-old man comes to the office due to a left scrotal mass that he first noticed a few months ago. The patient has scrotal heaviness and an increase in the size of the mass after prolonged standing at his job as a supermarket cashier. His symptoms improve when lying down. The patient plays basketball and has not had any scrotal trauma. He is sexually active with his girlfriend and uses condoms consistently. Physical examination shows an irregular, soft mass in the left scrotum above and separate from the left testis. The mass increases in size during Valsalva maneuver and does not transilluminate. Which of the following is the most likely cause of this patient's condition?

Question

A 22-year-old man comes to the office due to a left scrotal mass that he first noticed a few months ago.  The patient has scrotal heaviness and an increase in the size of the mass after prolonged standing at his job as a supermarket cashier.  His symptoms improve when lying down.  The patient plays basketball and has not had any scrotal trauma.  He is sexually active with his girlfriend and uses condoms consistently.  Physical examination shows an irregular, soft mass in the left scrotum above and separate from the left testis.  The mass increases in size during Valsalva maneuver and does not transilluminate.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d290_bb97_bc81_1bf64b41c160_MD0003_00 Painless scrotal masses are most commonly due to a hydrocele, inguinal hernia, or varicocele and less commonly caused by malignancy. This patient has a soft, irregular mass ("bag of worms") directly above the testis that increases in size with Valsalva and does not transilluminate. These findings are consistent with a varicocele, a tortuous dilation of the pampiniform plexus surrounding the spermatic cord and testis. Varicoceles typically present in adolescent and young adult males and are more common on the left side. They are often asymptomatic but may cause a dull ache after prolonged standing, as in this patient. varicocele Clinical examination can help differentiate between varicocele and inguinal hernia, which can also present as a painless, soft scrotal mass that does not transilluminate. Like varicoceles, indirect inguinal hernias (caused by a patent processus vaginalis) also increase in size with Valsalva maneuver. However, unlike varicoceles, hernias are often reducible with manipulation; in addition, palpation reveals a soft-tissue mass, unlike the characteristic "bag of worms" texture of a varicocele. A scrotal ultrasound can be useful if the diagnosis remains unclear after clinical examination. (Choice A) A spermatocele is a fluid-filled cyst of the head of the epididymis that transilluminates. It presents as a painless mass at the superior pole of the testis. A spermatocele does not change in size with positioning or Valsalva maneuvers. spermatocele (Choice C) Hydroceles are peritoneal fluid collections between the parietal and visceral layers of the tunica vaginalis. Although communicating hydroceles can change size with positioning, the fluid within a hydrocele is easily transilluminated. Hydroceles (Choice D) Testicular cancer is a rare but potentially life-threatening, firm testicular mass that does not change with Valsalva maneuvers or positioning. (Choice E) Widening of the femoral ring can lead to a femoral hernia. Femoral hernias occur most commonly in older women, do not protrude into the scrotum, and present with discomfort at the upper thigh, groin, or pelvis. femoral hernia Educational objective: A varicocele is a dilation of the pampiniform plexus that presents as an irregular scrotal mass that increases in size with Valsalva maneuvers and does not transilluminate. References: The varicocele. (http://www.ncbi.nlm.nih.gov/pubmed/24286772)

A 22-Year-Old Man Comes to the Office Due to a Left