Varicocele, Hydrocele, and Spermatocele

Varicocele

Definition

Varicocele is the abnormal dilation and tortuosity of the pampiniform venous plexus within the spermatic cord Spermatic Cord Either of a pair of tubular structures formed by ductus deferens; arteries; veins; lymphatic vessels; and nerves. The spermatic cord extends from the deep inguinal ring through the inguinal canal to the testis in the scrotum. Testicles: Anatomy, which is connected to the internal spermatic or gonadal vein.

Epidemiology

• Affects about 15%–20% of the general male population and up to 40% of men evaluated for primary infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
• Mostly unilateral and left sided 
• Bilateral presentation in 33% of males

Pathophysiology

• Increased intravascular venous pressure via compression Compression Blunt Chest Trauma:
  • The left gonadal vein drains into the left renal vein Renal vein Short thick veins which return blood from the kidneys to the vena cava. Glomerular Filtration at a right angle, whereas the right gonadal vein drains directly into the inferior vena cava Inferior vena cava The venous trunk which receives blood from the lower extremities and from the pelvic and abdominal organs. Mediastinum and Great Vessels: Anatomy.
  • Venous valve incompetence is another key contributor to increased venous pressure.
  • “Nutcracker effect”:
    • ↑ Left renal venous pressure due to the anatomic position of the left renal vein Renal vein Short thick veins which return blood from the kidneys to the vena cava. Glomerular Filtration (the vein is compressed between the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy and superior mesenteric artery Superior mesenteric artery A large vessel supplying the whole length of the small intestine except the superior part of the duodenum. It also supplies the cecum and the ascending part of the colon and about half the transverse part of the colon. It arises from the anterior surface of the aorta below the celiac artery at the level of the first lumbar vertebra. Small Intestine: Anatomy) 
    • Elevated renal vein Renal vein Short thick veins which return blood from the kidneys to the vena cava. Glomerular Filtration pressure → ↑ left gonadal vein pressure → retrograde blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure toward the testis 
    • Effect: dilatation of the vein and pampiniform venous complex 
• Secondarily, tumors/masses (right side) can produce the same effect.

Clinical presentation

• Usually painless
• When discomfort occurs, it is typically a dull, dragging ache that worsens with standing or Valsalva and improves when lying down.
• Acute onset of dull aching pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways may indicate a thrombotic event.
• Testicular atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation from slightly increased scrotal temperatures 
• Can present with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility

An isolated right-sided varicocele, sudden onset, failure to decompress, or new onset in an older patient raises concern for a renal or retroperitoneal Retroperitoneal Peritoneum: Anatomy mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast causing venous obstruction.

Diagnosis

Examination:

• Physical exam:
  • General genitourinary inspection Inspection Dermatologic Examination 
  • Assess for testicular atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation bilaterally.
• Exam maneuvers:
  • Valsalva maneuver: “bag of worms” on palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination
  • Standing position: most prominent representation of varicocele 
  • Supine position: usually see decompression and disappearance of low-grade varicoceles 
• Grades I to III:
  • I: palpable only with Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse 
  • II: not visible on inspection Inspection Dermatologic Examination, but palpable upon standing
  • III: visible on gross inspection Inspection Dermatologic Examination 

Imaging (scrotal ultrasound):

• Transillumination Transillumination Passage of light through body tissues or cavities for examination of internal structures. Male Genitourinary Examination: negative
• Doppler Doppler Ultrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow. Ultrasound (Sonography): several anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) tubes
• Delineating dilated venous complex with retrograde blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure
• Ultrasound typically shows pampiniform veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology measuring at least 3 mm in diameter, often with venous reflux.

Management

Treatment approach:

• Asymptomatic cases: No treatment is required; young men with normal semen analysis Semen analysis The quality of semen, an indicator of male fertility, can be determined by semen volume, ph, sperm concentration (sperm count), total sperm number, sperm viability, sperm vigor (sperm motility), normal sperm morphology, acrosome integrity, and the concentration of white blood cells. Infertility may be monitored every 1 to 2 years.
• Mild discomfort: Scrotal support and antiinflammatory drugs, with routine follow-up exams as indicated.
• Persistent pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, testicular atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation, or infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility: Varicocelectomy (including microsurgical gonadal vein ligation Ligation Application of a ligature to tie a vessel or strangulate a part. Esophageal Atresia and Tracheoesophageal Fistula) or percutaneous venous embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding.

Clinical considerations:

• Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility: a couple’s inability to conceive for a period of 1 year after actively trying to become pregnant:
  • Workup consists of physical exam, semen analysis Semen analysis The quality of semen, an indicator of male fertility, can be determined by semen volume, ph, sperm concentration (sperm count), total sperm number, sperm viability, sperm vigor (sperm motility), normal sperm morphology, acrosome integrity, and the concentration of white blood cells. Infertility, and sometimes scrotal ultrasound to rule out subclinical varicocele. 
  • Venous pooling impairs heat Heat Inflammation exchange in the pampiniform plexus, increasing testicular temperature and damaging the germinal epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology; this can lead to oligospermia and infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility.
• Renal cell carcinoma Renal cell carcinoma Renal cell carcinoma (RCC) is a tumor that arises from the lining of the renal tubular system within the renal cortex. Renal cell carcinoma is responsible for 80%-85% of all primary renal neoplasms. Most RCCs arise sporadically, but smoking, hypertension, and obesity are linked to its development. Renal Cell Carcinoma ( RCC RCC Renal cell carcinoma (RCC) is a tumor that arises from the lining of the renal tubular system within the renal cortex. Renal cell carcinoma is responsible for 80%-85% of all primary renal neoplasms. Most RCCs arise sporadically, but smoking, hypertension, and obesity are linked to its development. Renal Cell Carcinoma): 
  • Usually asymptomatic, but may present with flank pain Flank pain Pain emanating from below the ribs and above the ilium. Renal Cell Carcinoma or hematuria Hematuria Presence of blood in the urine. Renal Cell Carcinoma
  • Suspect if the patient has a right-sided varicocele.
  • Right varicocele forms from the compressive effect of the renal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast (on the blood vessels) or from an associated thrombus:
    • Diagnosis: renal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast on imaging (via contrast-enhanced cross-sectional imaging)
    • Treatment is primary tumor Tumor Inflammation resection.

Hydrocele

Definition

Hydrocele is a collection of serous fluid between the parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy and visceral layers of the tunica vaginalis Tunica vaginalis Testicles: Anatomy surrounding the testis. If bloody, the condition is referred to as hematocele.

Epidemiology and etiology

• Overall approximately 1% incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency
• Common in infants (typically congenital) and in adult men (typically acquired)
• Causes:
  • Congenital: patent processus vaginalis (outpouching of parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy)
  • Acquired: secondary to infection (e.g., filariasis) or trauma

Pathophysiology

Multifactorial, consisting of anatomic and fluid factors:

• Patent processus vaginalis leading to fluid transport to scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy 
• Impaired peritoneal fluid absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption 
• In noncommunicating hydroceles, an imbalance between local fluid secretion Secretion Coagulation Studies and resorption leads to fluid accumulation, sometimes following irritation of the tunica vaginalis Tunica vaginalis Testicles: Anatomy.
• Excessive fluid production from iatrogenic Iatrogenic Any adverse condition in a patient occurring as the result of treatment by a physician, surgeon, or other health professional, especially infections acquired by a patient during the course of treatment. Anterior Cord Syndrome causes such as:
  • Epididymo-orchitis Epididymo-Orchitis Epididymitis and Orchitis 
  • Trauma 
  • Testicular torsion Testicular torsion Testicular torsion is the sudden rotation of the testicle, specifically the spermatic cord, around its axis in the inguinal canal or below. The acute rotation results in compromised blood flow to and from the testicle, which puts the testicle at risk for necrosis. Testicular Torsion

Clinical presentation

• Painless, soft, cystic Cystic Fibrocystic Change scrotal swelling Swelling Inflammation (most common presentation)
• Difficulty walking
• Progressive heaviness and a dull ache in the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy
• In infants with a communicating hydrocele, swelling Swelling Inflammation may increase during the day and decrease at night as fluid shifts between the abdomen and scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy.

Diagnosis

• Physical exam:
  • General genitourinary inspection Inspection Dermatologic Examination 
  • Difficult to palpate testicles Testicles The testicles, also known as the testes or the male gonads, are a pair of egg-shaped glands suspended within the scrotum. The testicles have multiple layers: an outer tunica vaginalis, an intermediate tunica albuginea, and an innermost tunica vasculosa. The testicles are composed of testicular lobules and seminiferous tubules. Testicles: Anatomy due to surrounding fluid sac 
  • Tense scrotal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions 
• Exam maneuvers:
  • Shine pen light to scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy and see transillumination Transillumination Passage of light through body tissues or cavities for examination of internal structures. Male Genitourinary Examination signifying fluid. 
  • Absent reducibility of swelling Swelling Inflammation   
• Scrotal ultrasound:
  • Transillumination Transillumination Passage of light through body tissues or cavities for examination of internal structures. Male Genitourinary Examination: positive 
  • Visualize anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) fluid surrounding the testicle

Management

• Infants:
  • Most noncommunicating hydroceles resolve spontaneously during the first year of life; reassurance Reassurance Clinician–Patient Relationship is appropriate.
  • Surgical repair may be required if the hydrocele persists or an associated hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias is present.
• Adults:
  • Treat the underlying cause.
  • Conservative measures may include scrotal support underwear and optimized medical fluid management.
  • Surgically excise the hydrocele if it is large or symptomatic.
• Avoid aspiration because of high recurrence and infection risk.

Spermatocele

Overview

• Spermatocele is a paratesticular epididymal cyst with sperm-containing fluid.
• Commonly arises from the head (caput) of the epididymis Epididymis The convoluted cordlike structure attached to the posterior of the testis. Epididymis consists of the head (caput), the body (corpus), and the tail (cauda). A network of ducts leaving the testis joins into a common epididymal tubule proper which provides the transport, storage, and maturation of spermatozoa. Testicles: Anatomy

Pathophysiology

• Occlusion by agglutinated germ cells Germ Cells The reproductive cells in multicellular organisms at various stages during gametogenesis. Gametogenesis
• Gestational diethylstilbestrol Diethylstilbestrol A synthetic nonsteroidal estrogen used in the treatment of menopausal and postmenopausal disorders. It was also used formerly as a growth promoter in animals. According to the fourth annual report on carcinogens, diethylstilbestrol has been listed as a known carcinogen. Noncontraceptive Estrogen and Progestins (DES) exposure
• Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and epididymal scarring Scarring Inflammation leading to adhesions with formation of loculated collections containing spermatozoa

Clinical presentation

• Incidental scrotal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast on exam 
• Usually painless 
• Aching, discomfort, and heaviness of the affected testicle in larger variants

Diagnosis

• Physical exam: Often, mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast is located at the head of the epididymis Epididymis The convoluted cordlike structure attached to the posterior of the testis. Epididymis consists of the head (caput), the body (corpus), and the tail (cauda). A network of ducts leaving the testis joins into a common epididymal tubule proper which provides the transport, storage, and maturation of spermatozoa. Testicles: Anatomy. 
• Imaging:
  • Scrotal ultrasound: cystic Cystic Fibrocystic Change lesions from the epididymis Epididymis The convoluted cordlike structure attached to the posterior of the testis. Epididymis consists of the head (caput), the body (corpus), and the tail (cauda). A network of ducts leaving the testis joins into a common epididymal tubule proper which provides the transport, storage, and maturation of spermatozoa. Testicles: Anatomy
  • Color Doppler Doppler Ultrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow. Ultrasound (Sonography): characteristic “falling snow” appearance/sign (movement of internal echoes away from transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography), indicating solid particles)

Management

• Conservative: serial scrotal exams, scrotal support underwear 
• Medical: oral analgesics with NSAIDs NSAIDS Primary vs Secondary Headaches for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with scrotal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
• Surgical: spermatocelectomy

Differential Diagnosis

Scrotal swelling Swelling Inflammation or mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast has the following differential diagnoses:

• Testicular cancer Testicular cancer Testicular cancer is the most common solid malignancy affecting men 15-35 years of age. Most of the testicular cancers are of the germ cell tumor type, and they can be classified as seminomas and nonseminomas. The most common presentation of testicular cancer is a painless testicular mass. Testicular Cancer: the most common solid tumor Tumor Inflammation affecting men between ages 15–40 years. Testicular cancer Testicular cancer Testicular cancer is the most common solid malignancy affecting men 15-35 years of age. Most of the testicular cancers are of the germ cell tumor type, and they can be classified as seminomas and nonseminomas. The most common presentation of testicular cancer is a painless testicular mass. Testicular Cancer frequently presents as a painless testicular mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. Examination shows a firm mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast, with negative transillumination Transillumination Passage of light through body tissues or cavities for examination of internal structures. Male Genitourinary Examination on ultrasound. Initial management for a primary tumor Tumor Inflammation is radical orchiectomy.
• Inguinal canal Inguinal canal The tunnel in the lower anterior abdominal wall through which the spermatic cord, in the male; round ligament, in the female; nerves; and vessels pass. Its internal end is at the deep inguinal ring and its external end is at the superficial inguinal ring. Inguinal Canal: Anatomy and Hernias and hernias: bulge in the inguinal area Inguinal area The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination or scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy due to herniation Herniation Omphalocele of the bowel or omentum Omentum Peritoneum: Anatomy through the canal. Indirect inguinal hernias Indirect inguinal hernias Inguinal Canal: Anatomy and Hernias are the most common type of hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias and most are congenital. Diagnosis is by physical examination with patient straining, and on ultrasound, negative transillumination Transillumination Passage of light through body tissues or cavities for examination of internal structures. Male Genitourinary Examination is noted. Management is surgical repair when indicated.
• Generalized edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema ( liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis): Scrotal swelling Swelling Inflammation also occurs in conditions associated with hypoproteinemia and increased hydrostatic pressure Hydrostatic pressure The pressure due to the weight of fluid. Edema such as liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis. Swelling Swelling Inflammation is not just localized in the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy but is systemic, often in the abdomen ( ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites) and the lower extremities. Management involves addressing the underlying condition.