Blackwell Science, LtdOxford, UK IJU International Journal of Urology 0919-81722003 Blackwell Science Asia Pty Ltd 104April 2003 604 Intratesticular varicocele MA Pourbagher et al. 10.1046/j.0919-8172.2003.00604.x Case Report231232BEES SGML
International Journal of Urology (2003) 10, 231–232
Case Report
Intratesticular varicocele: Report of two cases MIR ALI POURBAGHER,1 SEZGIN GUVEL,2 AYSIN POURBAGHER1 AND FERHAT KILINC2 Departments of 1Radiology and 2Urology, Baskent University, School of Medicine, Adana Research and Teaching Center, Adana, Turkey Abstract
Intratesticular varicocele is a rare entity and describes dilated intratesticular veins radiating from the mediastinum testis into the testicular parenchyma. Scrotal ultrasonography of two patients who presented to our urology clinic due to left scrotal pain revealed multiple tubular structures in the testes with diameters of more than 2 mm. Duplex spectral analysis showed a reversed flow response to Valsalva’s maneuver. Apropos of two cases, intratesticular varicocele is reviewed.
Key words
color Doppler ultrasonography, intratesticular varicocele, testis, varicocele.
Introduction
Case 2
Intratesticular varicocele (ITV) is described as dilated intratesticular veins radiating from the mediastinum testis into the testicular parenchyma. It is a very rare entity and a limited number of cases have been reported previously. Apropos of two cases, ITV is reviewed.
A 67-year-old man presented because of left scrotal pain that had persisted for 10 years. The patient claimed that his left testis had decreased in size gradually over the past 15 years. On physical examination, the left testis was found to be atrophic. On scrotal ultrasonography, the left testis was 20 ¥ 11 ¥ 12 mm in size, and the right testis was 40 ¥ 21 ¥ 22 mm. Scrotal ultrasonography revealed multiple tubular structures with diameters of 2.5 mm in the left testis and ipsilateral ETV and duplex spectral analysis showed a reversed flow response to Valsalva’s maneuver (Fig. 2). There was no history of infertility, infection, operation or trauma in either patient. Treatment options such as varicocelectomy, sclerotherapy, analgesics and conservative management were discussed with the patients. Both patients preferred conservative treatment.
Case reports Case 1
A 56-year-old man presented to our urology clinic with a 2-year history of left scrotal pain. Physical examination of the scrotum showed no abnormality. On scrotal ultrasonography, the left testis was 40 ¥ 20 ¥ 23 mm in size, and the right testis was 38 ¥ 23 ¥ 22 mm. Scrotal ultrasonography revealed multiple tubular structures with diameters of 2.1 mm in the left testis and ipsilateral extratesticular varicocele (ETV) and duplex spectral analysis showed a reversed flow response to Valsava’s maneuver, diagnostic of varicocele (Fig. 1).
Correspondence: Sezgin Güvel MD, Bas¸kent Üniversitesi Adana Hastanesi, Dadalo gˇlu Mah, 39 Sk. No. 6, 01250, Adana, Turkey. Email:
[email protected] Received 15 April 2002; accepted 28 October 2002.
Discussion Although ETV is a common clinical condition, ITV is an extremely rare entity. Das et al. reported the incidence of ITV as 1.7% in 1040 symptomatic patients. The incidence in patients with infertility was 16%. The incidence of ITV was 2 (0.05%) in 3920 patients who underwent scrotal ultrasonography for other reasons in our hospital. Generally, ITV occurs on the left side and is associated with ipsilateral ETV, but it can also be
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Fig. 1 Longitudinal color Doppler image of the testis demonstrates dilated veins within the testis. Pulsed Doppler waveform documents venous reflux within this vessel during Valsalva.
structures may be found in and around the mediastinum testis on ultrasonography, the reflux in the veins during Valsalva’s maneuver shown by duplex Doppler ultrasound is a pathognomonic finding.4 However, some authors suggest that the venous structures need to be 2 mm or greater in diameter in order to establish a diagnosis.5 Differential diagnosis includes intratesticular cysts, tubular ectasia of rete testis, hematoma, focal infection and cystic intratesticular neoplasms, but color Doppler ultrasound is accurate for the differentiation of ITV from other causes.1 Treatment options are similar to ETV. Das et al. showed complete disappearance of ITV 12 weeks after varicocelectomy was performed for ETV in a patient.1 Successful results have also been reported by percutaneous sclerotherapy and percutaneous embolization.6,7 It is known that varicocele can be a cause of testicular atrophy.8,9 Progressive testicular atrophy can probably be prevented if varicocele ligation is performed at an early age.
References 1
2 3 4 5 Fig. 2 Similar view demonstrates dilated veins within atrophic testis and venous reflux.
found as solely intratesticular.1 Although the clinical implications and pathogenesis of ITV is unclear, it is believed to be the same as ETV because of its similar flow characteristics.2 Testicular pain is the most common complaint, while tenderness, scrotal mass and infertility are other common symptoms.3 Although infertility is a common symptom, there was no history of infertility in our patients. While tubular
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