Varicocele: The Daily PANCE Blueprint
A 17-year-old boy presents for a sports physical. He reports a dull, dragging ache in his left scrotum that is worse after standing all day and during football practice and improves when he lies down. He has no dysuria, fever, or trauma. Which of the following findings would you most expect on examination?
A. A firm, painless testicular mass that does not transilluminate
B. A smooth, fluid-filled scrotal swelling that transilluminates
C. A soft "bag of worms" above the testis that enlarges with Valsalva and shrinks when supine
D. A high-riding testis with an absent cremasteric reflex
E. A tender epididymis with pain relieved by elevating the testis
Answer and topic summary
The answer is C. A soft “bag of worms” above the testis that enlarges with Valsalva and shrinks when supine
A varicocele is a dilated pampiniform venous plexus. About 90% are left-sided, because the left gonadal vein drains at a right angle into the higher-pressure left renal vein. It feels like a “bag of worms” above the testis, best examined standing; it enlarges with Valsalva and decompresses when supine, which matches the ache that builds through the day. Varicoceles are associated with infertility and testicular atrophy, and scrotal ultrasound with Doppler confirms them. Red flag: a right-sided or nondecompressing varicocele needs imaging for a retroperitoneal mass such as renal cell carcinoma. Adolescents with a size difference between the testes, persistent pain, or abnormal semen analysis are referred for repair. Hydroceles transilluminate, a firm painless mass is cancer until proven otherwise, an absent cremasteric reflex is torsion, and relief with elevation (Prehn sign) suggests epididymitis.
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