Intratesticular varicocele

Left Scrotal Pain in 64M • Xray of the Week 2016 • Week #50

This 64 year old male presented with left scrotal pain. There is a history of undescended left testicle and orchiopexy at age 5. What is the diagnosis?

Video 1: Ultrasound demonstrating slow flow in an intratesticular varicocele.

Video 2: Zoomed ultrasound demonstrating slow flow in an intratesticular varicocele. The flow is too slow to be seen with color Doppler.

Figure 1. Intratesticular varicocele in a different patient. Color Doppler shows the dilated vein within the testis. Case courtesy of Dr Rupesh Namdev, Radiopaedia.org. From the case rID: 27305

Intratesticular varicocele is a rare cause of testicular pain seen in less than 2% of cases. Although usually associated with extratesticular varicocele, as seen in this case it is not invariable. Testicular pain is due to stretching of the tunica albuginea related to congestion and dilatation of veins [1]. Approximately 9% of men who have had prepubertal orchiopexy for undescended testis eventually develop an intratesticular varicocele [2]. Slightly more than half of the cases occur on the left side [1,2,3]. In 1992, Weiss et al reported the first 2 cases of intratesticular varicocele, describing straight or serpentine hypoechoic structures within the mediastinum testis radiating into the testicular parenchyma, identified as veins with color Doppler sonography [3]. However, slow flow may preclude Doppler signal, and as seen in the videos above, flow can be appreciated with real time sonography [Videos 1 and 2]. Approximately 80% of the testes affected with intratesticular varicocele demonstrate atrophy [4].

References:

1. Das KM, Prasad K, Szmigielski W et-al. Intratesticular varicocele: evaluation using conventional and Doppler sonography. Abstract: AJR Am J Roentgenol. 1999;173 (4): 1079-83. Full Text PDF

2. Meij-de Vries A, den Bakker FM, van der Wolf-de Lijster FS et-al. High prevalence of intratesticular varicocele in a post-orchidopexy cohort. J Pediatr Urol. 2013;9 (3): 328-33. doi:10.1016/j.jpurol.2012.04.004 - Pubmed citation

3. Weiss AJ, Kellman GM, Middleton WD, Kirkemo A. Intratesticular varicocele: sonographic findings in two patients. AJR Am J Roentgenol 1992; 158:1061–1063

4. Tétreau R, Julian P, Lyonnet D, et al. Intratesticular Varicocele: An Easy Diagnosis But Unclear Physiopathologic Characteristics. J Ultrasound Med 2007; 26:1767–1773

Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.

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