A 16-year-old boy comes to the office due to occasional discomfort and heaviness of his scrotum over the past several months. He has had no trauma, dysuria, or urethral discharge. The patient is not sexually active. He is afebrile, and vital signs are within normal limits. On physical examination, an irregular, ropy mass is noted on both sides of the upper scrotum. The mass increases in size with Valsalva and reduces on supine positioning. There is no erythema, ulcers, or tenderness of the scrotal skin and no inguinal lymphadenopathy. The remainder of the examination is normal. Surgical correction is discussed with the patient and his parents. The primary reason to perform surgery is to prevent which of the following complications in this patient?

Question

A 16-year-old boy comes to the office due to occasional discomfort and heaviness of his scrotum over the past several months.  He has had no trauma, dysuria, or urethral discharge.  The patient is not sexually active.  He is afebrile, and vital signs are within normal limits.  On physical examination, an irregular, ropy mass is noted on both sides of the upper scrotum.  The mass increases in size with Valsalva and reduces on supine positioning.  There is no erythema, ulcers, or tenderness of the scrotal skin and no inguinal lymphadenopathy.  The remainder of the examination is normal.  Surgical correction is discussed with the patient and his parents.  The primary reason to perform surgery is to prevent which of the following complications in this patient?

Quizplus · Accepted Answer

11ec25c8_d92e_2695_bc81_e97b44cd76b0_MD0003_00 A varicocele is a tortuous dilation of the pampiniform plexus of veins surrounding the spermatic cord and testis. It occurs in nearly 20% of men (usually between age 15-25) and presents as a soft, irregular mass ("bag of worms") that increases in size with standing and Valsalva. Reduction on supine positioning (due to decompression of the plexus) can also be seen. Varicoceles are more common on the left side because the left spermatic vein drains to the left renal vein, which is vulnerable to compression where it passes between the superior mesenteric artery and the aorta. Bilateral varicoceles are also common; however, unilateral right varicoceles are relatively rare and should raise suspicion for thrombosis or malignant compression. left side The diagnosis of varicocele can be confirmed on ultrasound, which shows dilation of the pampiniform plexus and retrograde venous flow. Initial interventions for scrotal discomfort due to a varicocele include scrotal support and simple analgesics (eg, nonsteroidal anti-inflammatory drugs). Varicoceles are associated with increased risk for infertility and testicular atrophy, which may be due to slightly increased scrotal temperature. For older men who do not have concerns about fertility, no intervention may be needed. However, younger men should be followed for signs of testicular atrophy or changes in semen analysis; abnormal findings generally warrant surgical intervention. When intervention is indicated, surgical venous ligation can improve fertility. (Choice A) Chronic epididymitis is usually a noninfectious inflammatory process, and is believed in most cases to be related to retrograde flow of urine into the epididymis. It carries an independent risk of infertility, but it is not a complication of varicocele. (Choice C) Intestinal strangulation is a potential complication of inguinal hernia, which can cause a bulge in the groin and extend into the scrotum but would not have a "bag of worms" (ropy) texture and is less likely to reduce in supine position. (Choices D and F) A hydrocele is a fluid collection within the tunica vaginalis; it typically presents in newborns as a painless scrotal swelling, although it is occasionally seen in adult men. On rare occasions, large hydroceles can cause irritation and ulceration in the overlying skin. In addition, congenital hydroceles are associated with an increased risk for testicular torsion due to inadequate fixation of the lower pole of the testis to the tunica vaginalis. This patient's irregular scrotal mass that changes in size with position is more consistent with varicocele. (Choice E) The risk of testicular cancer is increased in patients with cryptorchidism (ie, undescended testis), but cancer is not a notable complication of varicocele. Educational objective: A varicocele is a tortuous dilation of the pampiniform plexus surrounding the spermatic cord and testis. It presents as a soft, irregular mass that increases in size with standing and Valsalva. The diagnosis is confirmed with ultrasound. Initial interventions include scrotal support and simple analgesics. Varicoceles are associated with increased risk for infertility; for patients with testicular atrophy or changes in semen analysis, surgical venous ligation can improve fertility. References: Varicocele-induced infertility: newer insights into its pathophysiology. (http://www.ncbi.nlm.nih.gov/pubmed/21716891)

A 16-Year-Old Boy Comes to the Office Due to Occasional