VARICOCELE, HEMATOCELE, TORSION
Varicocele is defined as abnormal dilation and tortuosity of the
pampiniform plexus of veins in the spermatic cord. Most varicoceles (90%) occur
on the left side. The left internal spermatic vein terminates in the left renal
vein at right angles, an insertion without a natural valve (see Plate 3-2). In
contrast, the right internal spermatic vein enters the vena cava obliquely
below the right renal vein. With varicocele, the blood flow in the internal
spermatic veins is reversed, causing warm, corporeal blood to pool around the
normally cooler testis. Varicoceles occur in about 15% of young men. The
occurrence of an isolated right varicocele, or the sudden onset of a left
varicocele after the age of 30, may indicate retroperitoneal disease, such as
tumor, lymphadenopathy, hydronephrosis, or aberrant vessels. Most varicoceles
develop as a consequence of the pubertal growth spurt. When symptomatic, they
cause a pulling, dragging, or dull “congestive” discomfort in the testis and
scrotum, a pain that promptly disappears in the supine position. Varicoceles
are also the most common correctable cause of male factor infertility. The
differential diagnosis on presentation includes epididymitis and inguinal
hernia. Operative treatment is indicated (1) for
ipsilateral orchalgia, (2) for male factor infertility in the presence of at
least 1 year of adequate female fertility potential, and (3) when there is
evidence of ipsilateral testicular atrophy in an adolescent.
Varicocele treatment
consists of surgical ligation of the internal spermatic veins at the
retroperitoneal (Palomo and modified Palomo procedure), inguinal (Ivanissevitch
procedure), or subinguinal microscopic (Marmar procedure) approaches. In
addition, laparoscopic ligation and radiographic embolization can also be
attempted at the retroperitoneal level. The recurrence rate for ligation at the
retroperitoneal level is approximately threefold higher than that for
procedures at the inguinal or subinguinal level.
Hematocele is hemorrhage
into the tunica vaginalis space, usually as a result of traumatic or surgical
injury or testis tumor. Spontaneous hematocele is a known complication of
arteriosclerosis, scurvy, diabetes, syphilis, neoplasia, and inflammatory
conditions of the testis, epididymis, or tunica vaginalis. Hematocele may occur
from birth injury and may also develop in various blood dyscrasias. Following
injury, hematocele is accompanied by scrotal edema, as the hematoma permeates
the skin and subcutaneous tissues, lending the scrotal and penile skin a black
appearance. A slowly developing hematocele may be indistinguishable from
hydrocele except by its opacity to transillumination. Aspiration of bloody,
rather than clear, fluid leads to a definitive diagnosis. If the diagnosis and
etiology of hematocele are in doubt, surgical exploration is warranted to
deter- mine the underlying condition.
Axial rotation or torsion of
the spermatic cord results in infarction and gangrene of the testicle. A
720-degree rotation is required for most cases of clinical torsion. Torsion
occurs with equal frequency on either testis side, and also in the setting of
cryptorchidism. The main predisposing factor is abnormal mobility of the testis, usually due to a high insertion of the tunica on the spermatic
cord, also termed the “bell clapper” deformity. The extent of the damage to the
testicle depends upon the degree and duration of the torsion. If uncorrected
torsion persists for longer than 8 hours, complete testis infarction is likely.
The success of surgical detorsion procedures is directly related to the
duration of torsion. Although manual detorsion using palpation alone is
possible, torsion is normally treated by open surgery,
at which time the testis is either removed if unviable or fixed to the scrotal
wall or septum to preclude recurrence.
Torsion of the vestigial
appendix testis or the appendix epididymis may also cause acute scrotal pain
that must be differentiated from acute epididymitis and true testis torsion.
Occurring most commonly in young boys, it can present with a “blue dot” sign as
the necrotic appendix is viewed through the scrotal skin.
