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Difficulty: HardUrologic Surgery

A 6565-year-old man presents to the clinic complaining of left-sided scrotal swelling and discomfort that he first noticed 11 month ago. The patient describes a dull, heavy ache in the scrotum that worsens after standing for prolonged periods. Over the past 22 weeks, he has also experienced intermittent left flank pain and noticed that his urine occasionally appears pink. His medical history is significant for hypertension and a 4040-pack-year smoking history. Vital signs are within normal limits. Physical examination in the standing position reveals a soft, irregular, cord-like mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decrease in size. The testicles are bilaterally smooth, non-tender, and without discrete nodules. Which of the following is the most appropriate next step in the management of this patient?

  1. Computed tomography of the abdomenAnswer
  2. B
    Empiric ciprofloxacin therapy
  3. C
    Scrotal ultrasonography
  4. D
    Observation and supportive care with NSAIDs
  5. E
    Immediate surgical exploration of the scrotum

Answer

Computed tomography of the abdomen
The correct answer is computed tomography of the abdomen. This patient's presentation of a left-sided scrotal mass described as feeling like a 'bag of worms' is classic for a varicocele. Primary varicoceles are due to venous valve incompetence and typically decompress when the patient assumes a supine position. However, a varicocele that fails to decompress when supine, especially in an older patient with a smoking history, flank pain, and hematuria, is highly suspicious for a secondary varicocele. The left testicular vein drains into the left renal vein at a perpendicular angle; obstruction of the left renal vein by a renal cell carcinoma or retroperitoneal lymphadenopathy leads to retrograde venous pressure and continuous varicocele engorgement. Therefore, the most appropriate next step in management is cross-sectional imaging of the abdomen (such as a CT scan) to evaluate the kidneys and retroperitoneum for a malignant mass.

Step-by-Step Solution

1
Analyze the physical examination findings.
The patient has a soft, irregular, cord-like scrotal mass that does not decrease in size when supine.
This specific clinical presentation is diagnostic of a secondary varicocele, distinct from a primary varicocele which decompresses when the patient lies flat.
2
Identify the associated symptoms and risk factors.
The presence of intermittent flank pain, macroscopic hematuria, older age, and a significant smoking history are identified.
These findings are classic red flags that strongly suggest an underlying urologic malignancy, specifically renal cell carcinoma.
3
Correlate the pathophysiology of the findings.
The left gonadal (testicular) vein drains directly into the left renal vein.
Obstruction of the left renal vein by a retroperitoneal process (such as a tumor thrombus from a renal cell carcinoma) leads to impaired venous drainage, retrograde pressure, and a secondary varicocele that remains engorged regardless of patient positioning.
4
Select the most appropriate diagnostic modality.
Computed tomography (CT) of the abdomen is chosen as the next step.
CT imaging of the abdomen and pelvis is necessary to directly visualize the kidneys, renal veins, and retroperitoneum to diagnose the obstructing lesion.

Key Concept

Evaluation of secondary varicoceles and suspected renal cell carcinoma
Estimated Time:1m 30s
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Topics

Urologic Surgery

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