PANCE Blueprint Genitourinary (5%)

Hydrocele and varicocele (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

Varicocele A 3-month-old with bilateral, enlarged, painless scrotum since birth (watch video)

Patient will present as  a 28-year-old male who comes to your clinic with his wife. They have been trying to get pregnant for the past 24 months without success. The patient was told that he had a low sperm count with 'poor quality' sperm. Examination reveals a scrotum that, on the right side only, is enlarged and feels like a 'bag of worms' on palpation. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown here.

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Varicocele = "bag of worms"

Hydrocele = transilluminates

Hydrocele

  • A hydrocele is a mass of the fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis.
  • Painless scrotal swelling (Most common cause of painless scrotal swelling)
  • Infants: will usually close within the 1'st year of life may require elective repair as clinically indicated
  • (+) Transillumination vs. Tumor  or varicocele which both do not transilluminate

Varicocele

  • A varicocele is the formation of a venous varicosity within the spermatic vein
  • Bag of worms superior to the testicle
  • Cystic testicular mass of varicose veins  – Dilation worse when the patient is upright or with Valsalva – decreases in size with an elevation of the scrotum or supine position.
  • (-) Transillumination – A chronic, nontender mass that does not transilluminate is seen.
  • Management may require surgery in some case.

Scrotal ultrasound can be used in the diagnosis of both hydrocele and varicocele

Hydrocele:  in infants will usually close within the 1'st year of life may require elective repair as clinically indicated.

Varicocele: surgical repair can be performed if the varicocele is painful or if it appears to be a cause of infertility.

IM_MED_Varicocele_v1.3 Varicocele occurs when the pampiniform plexus of veins within the spermatic cord becomes dilated, due to obstruction of venous drainage. Patients present with a soft, scrotal mass around the left testicle that feels like a bag of worms. The mass increases in size with standing or Valsalva maneuvers, and decreases in size when supine. Testicular atrophy and subfertility may occur if identification and treatment is delayed. Diagnosis is made using ultrasound to look for retrograde venous flow. Treatment includes supportive therapy and surgical gonadal vein ligation in unresolving cases.

Varicocele Picmonic

IM_NUR_Hydrocele_v1.2_ Hydrocele is a collection of fluid around the testicle or along the spermatic cord leading to a non-tender fluid-filled (cystic) mass. This occurs when lymphatic drainage from the scrotum is impaired, leading to swelling and enlargement. Hydrocele is common in newborns and typically disappears without treatment during the first year of life. However, treatment is indicated if the mass becomes large and uncomfortable. The hydrocele can be visualized with transillumination, and treatment consists of needle aspiration or surgery. Patients will require scrotal support after treatment, and they should be monitored for bleeding or infection at the site after intervention.

Hydrocele Picmonic

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Question 1
A 1-day-old male infant born by normal spontaneous vaginal delivery was found to have a scrotal mass on physical examination. The mass transilluminates and confirms the attending physician's suspicion of hydrocele. How long should the physician recommend that the parents wait before the hydrocele is reassessed?
A
1 day
Hint:
None of these time frames are correct. The parents should practice watchful waiting of the hydrocele for up to 1 full year. If after 1 year the hydrocele remains, they should seek reassessment by a physician for possible surgical management.
B
1 week
Hint:
None of these time frames are correct. The parents should practice watchful waiting of the hydrocele for up to 1 full year. If after 1 year the hydrocele remains, they should seek reassessment by a physician for possible surgical management.
C
1 month
Hint:
None of these time frames are correct. The parents should practice watchful waiting of the hydrocele for up to 1 full year. If after 1 year the hydrocele remains, they should seek reassessment by a physician for possible surgical management.
D
6 months
Hint:
None of these time frames are correct. The parents should practice watchful waiting of the hydrocele for up to 1 full year. If after 1 year the hydrocele remains, they should seek reassessment by a physician for possible surgical management.
E
1 year
Question 1 Explanation: 
The newborn baby boy in this vignette was found to have a hydrocele. Most hydroceles will resolve within the first 12 months of life and do not need to be reassessed unless present after 1 year.
Question 2
A 28-year-old male presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count with 'poor quality' sperm. Examination reveals a scrotum that, on the right side only, is enlarged and feels like a 'bag of worms' on palpation. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown in here. Which of the following is the best next step in the management or evaluation of this patient's presentation?
A
Observation with no further testing or management
Hint:
The signs in this patient's presentation suggestive of IVC obstruction warrant obtaining a CT abdomen.
B
MRI pelvis
Hint:
MRI of the pelvis does not have a role in evaluating varicocele or in evaluation of IVC obstruction.
C
CT abdomen
D
Embolization
Hint:
Embolization and surgical repair of varicocele are viable treatment options when indicated (such as cases where varicocele may be contributing to male infertility); however, the signs in this patient's presentation that are suggestive of possible IVC obstruction warrant further evaluation with a CT abdomen.
E
Surgical repair
Hint:
Embolization and surgical repair of varicocele are viable treatment options when indicated (such as cases where varicocele may be contributing to male infertility); however, the signs in this patient's presentation that are suggestive of possible IVC obstruction warrant further evaluation with a CT abdomen.
Question 2 Explanation: 
This patient's presentation is consistent with a varicocele. Right-sided varicocele, bilateral varicocele, and failure of a varicocele to disappear upon lying supine are signs suggestive of inferior vena cava (IVC) obstruction and warrant further investigation with a CT scan of the abdomen.
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