A 19-year-old man presents to his primary care physician with a concern about an unusual texture he noticed near his left testicle last week. He noticed this incidentally, and he denies any testicular pain or discomfort, penile discharge, or erectile dysfunction. He hasn’t noticed any changes in urine color and denies any dysuria or flank pain. He does not drink alcohol or smoke cigarettes and eats a healthy diet prescribed by a nutritionist. He admits to occasionally using nicotine pouches. He is sexually active in a monogamous relationship with a woman. He is on the college weightlifting team. Vital signs are within normal limits. On physical examination, there are no masses noted on palpation of the abdomen. The testicles are symmetric in size and shape. Examination of the scrotum in the standing position reveals the presence of a “bag of worms” texture adjacent to the left testicle. This is more noticeable when the patient is asked to perform a Valsalva maneuver. The abnormality does not transilluminate. Testicular size is the same on each side.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
C) Observation and return precautions
This patient is presenting with varicocele, which is caused by dilation of the pampiniform plexus of spermatic veins. It is most commonly found in adolescent and young adult aged males and is most often left-sided. Lifting heavy weights causes increased abdominal pressure which is an additional risk factor. The diagnosis of varicocele is clinical but can be confirmed by scrotal ultrasound if there is uncertainty. The patient does not pain, testicular hypotrophy, or evidence of infertility, so treatment of varicocele is not indicated.
Answer choice A: Cessation of nicotine usage, is incorrect. Although smoking can damage the gonads, nicotine itself is unrelated to varicocele.
Answer choice B: Computed tomography (CT) scan of the abdomen with contrast, is incorrect. This is indicated if there is suspicion for renal cell carcinoma, which can lead to varicocele. However, this patient denies hematuria and flank pain, and his abdominal exam is unremarkable.
Answer choice D: Prostate examination, is incorrect. Prostate examination would not add useful information in the evaluation of this patient.
Answer choice E: Referral for surgical embolization. Surgical treatment is not indicated in this patient as he does not have pain, testicular hypotrophy, or evidence of infertility.
Key Learning Point
Surgical treatment in varicocele is only indicated in symptomatic patients with persistent discomfort/pain not treated via medical management, low sperm count/infertility, or failure of testicular growth.
