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Difficulty: MediumUrologic Surgery

A 6262-year-old man comes to the urology clinic reporting a dull, aching heaviness in his left scrotum that has gradually worsened over the past 33 months. He denies any dysuria, urethral discharge, fever, or history of sexually transmitted infections. His medical history includes hypertension and a 3030-pack-year history of smoking. Vital signs are within normal limits. Physical examination of the patient in the standing position reveals a palpable, non-tender, tortuous, "bag of worms" mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decompress or reduce in size. Urinalysis shows 1515 red blood cells per high-power field, but is negative for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

  1. Computed tomography of the abdomenAnswer
  2. B
    Empirical therapy with levofloxacin
  3. C
    Reassurance and scrotal support garments
  4. D
    Scrotal ultrasonography with Doppler
  5. E
    Surgical exploration via an inguinal approach

Answer

The most appropriate next step is computed tomography of the abdomen to evaluate for an obstructing renal mass.
The correct answer is cross-sectional imaging of the abdomen. This patient presents with a newly diagnosed left-sided varicocele that fails to empty when he is recumbent, accompanied by microscopic hematuria and a significant smoking history. Primary varicoceles are common in younger men due to incompetent venous valves and typically decompress in the supine position. A secondary varicocele is one that does not decompress when supine, strongly suggesting a continuous proximal mechanical obstruction. Anatomically, the left gonadal vein drains perpendicularly into the left renal vein. A left-sided renal mass (such as renal cell carcinoma) can compress the renal vein or directly invade it with a tumor thrombus, blocking gonadal venous return and causing a secondary varicocele. Therefore, the immediate next step must evaluate the retroperitoneum and kidneys via computed tomography.

Step-by-Step Solution

1
Identify the primary clinical abnormality based on physical exam findings.
The patient has a left-sided varicocele that does not reduce in the supine position.
Differentiating between a primary varicocele (decompresses when supine) and a secondary varicocele (remains engorged when supine) is critical for determining etiology.
2
Correlate the physical exam finding with the patient's demographics and laboratory results.
The patient is an older male with a significant smoking history and concurrent microscopic hematuria.
Hematuria in an older smoker is a red flag for genitourinary malignancy, increasing the suspicion that the secondary varicocele is tumor-related.
3
Recall the anatomical venous drainage of the testicles.
The right gonadal vein drains directly into the inferior vena cava, while the left gonadal vein drains perpendicularly into the left renal vein.
Anatomy explains why left-sided varicoceles are more common, and why obstruction of the left renal vein directly causes left pampiniform plexus engorgement.
4
Determine the necessary diagnostic intervention.
Computed tomography of the abdomen is required to evaluate the kidneys and retroperitoneum.
A renal cell carcinoma or tumor thrombus in the left renal vein must be ruled out as the cause of the mechanical obstruction.

Key Concept

Secondary Varicocele and Renal Cell Carcinoma
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Topics

Urologic Surgery

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