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Difficulty: MediumUrologic Surgery

A 64-year-old man presents to the clinic with a 3-week history of a left-sided scrotal mass. He reports a dull, dragging sensation in his scrotum but denies acute pain, dysuria, or fever. His medical history is notable for hypertension and a 40-pack-year smoking history. Physical examination reveals a soft, non-tender, tortuous mass superior to the left testis. The mass does not decompress when the patient assumes a supine position. His abdomen is soft and non-tender. Urinalysis demonstrates 4-5 red blood cells per high-power field. Which of the following is the most appropriate next step in management?

  1. Computed tomography of the abdomen and pelvisAnswer
  2. B
    Scrotal ultrasonography with Doppler
  3. C
    Reassurance and use of a scrotal supporter
  4. D
    Empiric therapy with levofloxacin
  5. E
    Immediate surgical exploration of the scrotum

Answer

Computed tomography of the abdomen and pelvis is the appropriate next step to evaluate for an underlying renal mass or retroperitoneal pathology.
The correct answer identifies the need for cross-sectional imaging of the abdomen and pelvis. This patient presents with a secondary varicocele. Unlike primary (idiopathic) varicoceles, which typically occur in adolescents or young adults and empty when the patient lies supine, secondary varicoceles often occur in older men and do not decompress when supine. The left gonadal (testicular) vein drains directly into the left renal vein at a perpendicular angle. Any process that obstructs the left renal vein—most classically a Renal Cell Carcinoma (RCC) with tumor thrombus extension—can impede gonadal venous return, causing a varicocele. Given the patient's age, smoking history, and the presence of microscopic hematuria, RCC is the most critical diagnosis to rule out. Therefore, a CT scan of the abdomen and pelvis is the most appropriate next step.

Step-by-Step Solution

1
Analyze the physical examination findings.
The patient has a left-sided varicocele ('tortuous mass superior to the testis') that does not reduce in the supine position.
Identifying the clinical characteristics of the mass is essential to determine its etiology.
2
Correlate the physical findings with anatomy.
The left gonadal vein drains perpendicularly into the left renal vein. A varicocele that does not empty when gravity is eliminated (supine position) implies a fixed proximal obstruction.
Understanding venous drainage pathways explains why left-sided varicoceles can be secondary to renal vein obstruction.
3
Integrate patient risk factors and urinalysis.
The patient is older, has a significant smoking history, and has microscopic hematuria.
These findings raise the clinical suspicion for a urologic malignancy, specifically Renal Cell Carcinoma (RCC), which often invades the renal vein.
4
Determine the next best diagnostic step.
Cross-sectional imaging of the abdomen and pelvis is indicated to evaluate the kidneys and retroperitoneal structures.
Visualizing the kidneys is required to rule out an obstructing tumor before offering symptomatic management for the varicocele.

Key Concept

A left-sided varicocele that fails to empty when the patient is supine, particularly in an older man with hematuria, is highly suspicious for a left renal mass obstructing the renal vein and requires abdominal/pelvic CT imaging.

Alternative Method

While CT abdomen/pelvis is preferred for staging and evaluating a suspected renal mass, an abdominal ultrasound could be used as an initial, less invasive screening tool to evaluate the kidneys and renal veins if the patient had severe contrast allergy or renal failure, though CT remains the definitive next step in this clinical scenario.
Estimated Time:1m 30s
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Urologic Surgery

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