Monday, 25 July 2016

Test your Surgery Knowledge: Varicocele

A 14-year-old male presents for a routine physical examination. During a genital examination, you note a mass over the left testicle. This mass feels like a bag of worms, but resolves when you examine the patient in the supine position.
The most appropriate course of care would be:

a. Observation
b. Testicular volume evaluation
c. Immediate referral for surgical correction
d. Hormonal therapy
e. Referral to an infertility specialist when indicated

The correct answer is B.
This patient has a varicocele, which is not a normal variant but rather a collection of dilated and tortuous veins in the pampiniform plexus around the spermatic cord. The cause is not fully understood, but it has been hypothesized that varicoceles result from increased venous pressure and incompetent valves. Approximately 85%-95% occur on the left side, and if they are found on the right side or occur bilaterally, surgical intervention is recommended. Also, if the varicocele is large or painful, has an acute onset, or does not resolve in the supine position, a surgical referral should be made. Infertility is a problem for only 10%-15% of patients with varicoceles, and hormonal therapy is not recommended. Testicular volumes should be measured, and if the affected testicle has a volume 2 mL less than the normal testicle, referral is prudent.

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