Friday, July 13, 2012

Case Presentation

History:  Teenager with scrotal abnormality.

Scrotal US
Which choice best applies to the salient finding(s)?
Unilateral mass.

color doppler images

Findings:  Normal right testicle. Anechoic rounded and tubular structures surrounding left testicle with tubular structure seen extending into the left testicular parenchyma. Color Doppler ultrasound demonstrates flow within these structures with increased flow during Valsalva.

Differential diagnosis:
  • Intratesticular varicocele
  • Pseudoaneurysm
  • Intratesticular simple cysts
  • Tubular ectasia
  • Epidermoid cyst
  • Tunica albuginea cyst
  • Abscess
  • Hemorrhage

Diagnosis:  Intratesticular (and extratesticular) varicocele

Key points:
  • Varicoceles are dilated veins within the pampiniform plexus due to incompetent/absent venous valve near junction of left renal vein to IVC.
  • Intratesticular varicocele are similar to those of extratesticular varicocele and include multiple anechoic, serpiginous, tubular structures of varying sizes.
  • Intratesticular varicoceles can occur in association with extratesticular varicoceles, but their independent existence is more common.
  • Majority of varicoceles occur on the left (78%) with bilateral (16%) and right-sided (6%) occurring much less.
  • Patients with this condition may have pain related to passive congestion of the testis, which eventually stretches the tunica albuginea. Infertility can also occur.
  • Color flow and duplex Doppler US show a venous flow pattern with a characteristic venous spectral waveform, which increases with the Valsalva maneuver.
  • Catheter embolization, surgical treatment for antegrade sclerotherapy can be used to treat varicoceles if symptomatic or causing low sperm count.
1.   Dogra, V MD, Gottlieb, R MD "Benign Intratesticular Cystic lesions: US features." October 2001 RadioGraphics, 21, S273-S281.
2.   Paunipagar, B MD "Varicocele." 2010



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