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.