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Varicocele, Hydrocele, and Spermatocele

Benign Benign Fibroadenoma or nonacute scrotal masses are represented by hydroceles, varicoceles, and spermatoceles. Key components to evaluation are physical exam and scrotal ultrasound. Hydroceles represent extra fluid in the tunica vaginalis Tunica vaginalis Testicles: Anatomy, leading to a swollen scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy. Varicoceles have a dilatation of the pampiniform venous plexus, giving the “bag of worms” appearance on exam. Spermatoceles present as an epididymal cyst, commonly arising from 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. Hydroceles, varicoceles, and spermatoceles are usually asymptomatic and do not require treatment unless they are causing pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or other complications.

Last updated: 24 Feb, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Varicocele

Definition

Varicocele is the dilatation of the pampiniform venous plexus, which is connected to the internal spermatic or gonadal vein.

Varicocele

Varicocele: image showing left-sided dilated pampiniform venous plexus in the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy

Image: “Varicocele” by Samuel La’mert. License: CC BY 4.0

Epidemiology

  • Affects about 15%–20% of postpubertal males 
  • Mostly unilateral and left sided 
  • Bilateral presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor in 33% of males

Pathophysiology

  • Increased intravascular venous pressure via compression Compression Blunt Chest Trauma:
    • The left gonadal vein drains into the renal vein Renal vein Short thick veins which return blood from the kidneys to the vena cava. Glomerular Filtration (at a right angle).
    • “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 Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. 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 Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Usually painless
  • 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

Diagnosis

Examination:

  • Physical exam:
    • General genitourinary inspection 
    • Assess for testicular atrophy 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: 

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 Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure

Management

Treatment approach:

  • For older men (completed a family): conservative management (routine follow-up exams, scrotal support, antiinflammatory drugs)
  • For young men:
    • 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: Monitor every 1 to 2 years. 
    • 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 abnormal semen: surgery (microsurgical gonadal vein ligation Ligation Application of a ligature to tie a vessel or strangulate a part. Esophageal Atresia and Tracheoesophageal Fistula vs. 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
    • Varicoceles increase the temperature in the testis, decreasing spermatogenesis Spermatogenesis The process of germ cell development in the male from the primordial germ cells, through spermatogonia; spermatocytes; spermatids; to the mature haploid spermatozoa. Gametogenesis
  • 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 Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways 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 peritoneal fluid in the tunica vaginalis Tunica vaginalis Testicles: Anatomy surrounding the testes Testes Gonadal Hormones. If bloody, the condition is referred to as hematocele.

Epidemiology and etiology

  • Overall approximately 5% 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
  • Causes:
    • Congenital Congenital Chorioretinitis: 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 
  • 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 Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Increasing scrotal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and painless (most common presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor)
  • 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
Giant hydrocele

Hydrocele: enlarged scrotal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast filled with fluid

Image: “Hydrocele” by Dan Mischianu et al AL Amyloidosis. License: CC BY 2.0

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:
  • Scrotal ultrasound:
Hydrocele management

Transverse view of scrotal ultrasound showing hydrocele:
A: large left hydrocele as noted by the dark border delineating fluid surrounding the normal testicle in grey color
B: a smaller amount of fluid as a small hydrocele of the right testicle

Image: “Scrotal ultrasonography” by Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea. License: CC BY 3.0

Management

  • Conservative: scrotal support underwear and optimize medical fluid management 
  • Surgical: excision of the hydrocele sac (if symptomatic)

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 Exposure ABCDE Assessment
  • 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 Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • 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)
Spermatocele

Transverse view of a scrotal ultrasound: Testicle is grey structure to the right and spermatocele is fluid-filled sac on the left (darker).

Image: “Spermatocele” by Iwak. License: Public Domain

Management

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 15–35 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 Congenital Chorioretinitis. 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.

References

  1. Eyre, R.C. (2020). Nonacute scrotal conditions in adults. UpToDate. Retrieved January 21,2021, from https://www.uptodate.com/contents/nonacute-scrotal-conditions-in-adults
  2. Pais, V. (2019) What causes spermatocele? Medscape. Retrieved 22 Jan 2021 from https://www.medscape.com/answers/443432-159405/what-causes-spermatocele
  3. Pais, V. (2019) Spermatocele. Medscape. Retrieved Jan 22 2021 from https://emedicine.medscape.com/article/443432-overview
  4. Parke, J., Jafre, S. (2020) Hydrocele. Medscape. Retrieved 22 Jan 2021 from https://emedicine.medscape.com/article/443432-overview
  5. White, W., Kim, E. (2019) Varicocele. Medscape. Retrieved 22 Jan 2021 from https://emedicine.medscape.com/article/438591-overview

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