The Case:

A 25 year old male with no significant history presents for right-sided testicular pain. Over the last 3 days he has had constant right-sided testicular pain without any pain free intervals. He has noticed scrotal erythema and edema as well. Has never had this before. He believes he has no risk for STDs. No urinary or bowel symptoms. No systemic symptoms.

On exam the patient appears to be in pain. He has scrotal erythema that is noted as well as tenderness to palpation somewhat diffusely over the right testicle but more prominent on the posterior aspect. Left testicle examination is benign. No clinical signs of torsion. Penile exam benign. His abdominal exam is benign. Vitals are normal except mild tachycardia to 110.

Urinalysis is obtained and is negative. US obtained without signs of torsion. US revealed an isolated right varicocele with possible signs of inflammation. No signs of epididymitis.

The Unilateral Right Sided Varicocele

 

The veins that drain the testicles form the pampiniform plexus. These drain into the spermatic (gonadal) veins. The left spermatic vein drains into the left renal vein. The right spermatic vein drains directly into the IVC. A varicocele is dilation of the pampiniform plexus forming an area of dilated veins usually secondary to increased pressure (think varicose veins or esophageal varices). This usually happens on the left side because of the angle that the spermatic vein makes as it enters the renal vein. This should not happen on the right side since it drains directly into the IVC. A unilateral right sided varicocele is unusual and should raise suspicion for etiologies that can cause IVC obstruction (renal mass, propagating renal vein thrombosis, etc). These should be evaluated by CT of the abdomen/pelvis with IV contrast to further delineate cause of unilateral right sided varicocele.

Case Resolution:

The patient underwent a CT of the abdomen/pelvis with IV contrast to further delineate unilateral right sided varicocele with severe pain. CT abdomen/pelvis revealed right sided spermatic vein thrombosis. No signs of IVC or renal vein abnormalities and no masses in the abdomen. Urology consulted for spermatic vein thrombosis and recommendation was routine conservative therapy with anti-inflammatory medication and outpatient follow up for possible clot intervention if patient does not improve. No anticoagulation recommended. Patient will undergo a hypercoagulability workup as an outpatient.

Varicocele and Varicocele/Spermatic Vein Thrombosis Management

Most varicoceles do not require intervention. The objectives in treating a varicocele include relieving pain and improving testicular function (and potentially fertility). NSAIDs and scrotal support tend to be sufficient. For refractory symptoms and to potentially improve fertility, surgical ligation or coil embolization can be performed.

Varicocele and spermatic vein thrombosis are rare disease processes with only case reports in the literature. Causes of thrombosis should be explored including causes of renal vein and IVC obstruction/thrombosis as well as underlying hypercoagulability disease. Inflammatory conditions such as orchitis/epididymitis can also cause thrombosis. Treatment tends to be treatment of underlying disease process if there is one as well as symptomatic treatment. Anticoagulation is usually not indicated if there is not an underlying hypercoagulability disorder. Follow up with urology is indicated as surgical resection/thrombectomy can be performed if thrombosis does not resolve.

 

 

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Beau Stokes, MD

EM4, University of Michigan and St. Joseph Mercy Residency Program

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