Rare case of thrombosed varicocele causing severe scrotal and groin pain

In patients with acute scrotal pain, testicular torsion, and acute epididymo-orchitis are often the first diagnoses to be considered [1]. Once these pathologies have been excluded, less frequently encountered differentials should be investigated. Thrombosis of a testicular varicocele is a rare condition, reported in less than 50 cases [2]. Here we present the case of a male in his early twenties with left-sided groin and scrotal pain shown to be caused by a thrombosed varicocele.

A male in his twenties presented to the emergency department with five days of left-sided groin and scrotal pain. Pertinent negatives included no nausea, vomiting, dysuria, penile discharge, or changes in bowel habit. He was not sexually active and denied recent viral infection, lower limb cellulitis, or wounds. He had a past medical history of well-controlled asthma and mild scoliosis.

Physical examination demonstrated a firm, tender, irreducible, left groin lump along the spermatic cord between the pubic tubercle and upper border of left epididymis. The epididymis was non-tender. There was no inguinal or femoral hernia appreciable on physical examination on both supine and standing examinations. There was no swelling along the left inguinal canal, Hasselbach’s triangle, or femoral canal area. There was no cough impulse over the deep ring. Routine bloods showed mildly raised white cell count (WCC) (11.5) and C-reactive protein (CRP) (69.5). Urine dipstick and cultures were negative. Outpatient ultrasound (US) one day prior to presentation demonstrated a reducible, left-sided indirect inguinal hernia and normal testes. Computed tomography (CT) of the abdomen and pelvis was performed given the severity of the patient’s pain which confirmed a small, fat-containing left indirect inguinal hernia, without features of fat strangulation (Figure 1). Clinically, a decision was made not to operate on the patient for incidental, asymptomatic, image-detected small fatty hernia, and the patient was admitted for observation. Other key differentials that were excluded included testicular torsion, torsion of the appendix testis, epididymo-orchitis, acute abdominal pathology with radiation of pain to the scrotum, and painful lymphadenopathy.

The patient was managed with simple and opiate analgesia and intravenous (IV) antibiotics for possible epididymo-orchitis. His WCC and CRP trended downward and a repeat inpatient US of the testes and scrotum was performed which did not show sonographic evidence of acute epididymo-orchitis, or inguinal lymphadenopathy. The US again showed a small, fat-containing, reducible, left-sided indirect inguinal hernia with a 7 mm neck. Importantly there was no strangulation or probe tenderness over the hernia contents.

Repeat physical examination did not demonstrate clinical evidence of a hernia. The left testicle remained tender, and a painful, firm lump was again noted posterior to spermatic cord structures. Differentials for this were painful lymphadenopathy or a varicocele, so a targeted ultrasound of this region was performed. When imaging the lump, a non-compressible, serpiginous, 3 mm hypoechoic structure was seen with significant probe tenderness. It demonstrated internal echogenicity and no internal flow on color Doppler (Figure 2 and Figure 3). These findings favored a thrombosed left varicocele.

Based on a brief literature review, a decision was made to trial conservative treatment prior to proceeding with surgery. We did not identify any literature strongly supporting the use of anticoagulation for our patient, and he did not have any malignancy or known prothrombotic factors. The patient was discharged home with oral antibiotics, oral analgesia including non-steroidal anti-inflammatories, and advice regarding scrotal support. On follow-up three months later, the patient reported that the pain had reduced to a mild level two weeks after discharge, due to taking ibuprofen. The pain had completely resolved four weeks after discharge.

Here we present a case of a young male with spontaneous thrombosed left varicocele. A significant element of this case was the co-existence of an ultrasound-and CT-proven uncomplicated fat-containing indirect inguinal hernia, which caused diagnostic uncertainty. Relying solely on the imaging rather than clinical examination could have resulted in an unnecessary hernia operation, potentially worsening the patient’s groin pain considerably. Instead, repeated examination and focused imaging ensured a correct diagnosis which could be conservatively managed. Notwithstanding this, surgical exploration of undifferentiated acute scrotal pain remains an entirely appropriate option, particularly in instances where ultrasound is difficult to obtain in a timely fashion.

Whiteley et al. identified 41 cases of thromboses of the spermatic vein, pampiniform plexus, or testicular vein [2]. There was a predominance of left-sided thromboses, which is thought to relate to increased venous pressures within the system of left gonadal veins due to drainage via the left renal vein [3]. The patient we report also had left-sided thromboses, similar to previously reported cases. Less than half of patients reported by Whiteley et al. had associated trauma or high-intensity activity prior to development of pain [2]. A small number of reported cases developed thrombosis iatrogenically after varicocelectomy [2],[4]. Thrombosis related to an underlying prothrombotic hematological condition has also been described [5] . There were no aggravating mechanical or physiological factors present in our reported case. The clinical grading of a non-thrombosed varicocele allocates grade 0 for non-palpable varicoceles visualized only on ultrasound; grade 1 if palpable with Valsalva maneuver; grade 2 if palpable without Valsalva but not visible; and grade 3 for visible varicoceles [6]. Given their rarity, no grading system exists for thrombosed varicoceles.

Due to the paucity of published cases, there is no literature comparing physical examination to imaging in diagnosing thrombosed varicoceles or differentiating it from an incarcerated hernia. Importantly, ultrasound has 100% specificity for clinically palpable inguinal hernias, but this drops to 77% when the hernia is not appreciable on physical exam [7],[8]. Thus, some patients without a hernia but with a positive ultrasound may be committed to unnecessary surgery if the imaging findings are not closely correlated with physical examination. The diagnosis of a clinically suspected thrombosed varicocele is confirmed in most cases by ultrasound, particularly with the added advantage of color Doppler images [2],[9],[10]. A small number of patients also receive a CT scan, which can be helpful in distinguishing a thrombosed varicocele from other groin pathologies [2],[9]. In our case, the initial inpatient ultrasound did not demonstrate the varicocele but was performed by a general sonographer. The repeat targeted ultrasound was performed with both the surgical and radiology teams present to ensure the area of interest was properly imaged.

Management of thrombosed varicoceles remains controversial, with conservative and surgical options described. Conservative therapies include analgesia, anti-inflammatories, antibiotics, and anticoagulation. Surgical management is with either excision of the thrombosed varicocele or in some severe cases orchidectomy [2],[11]. The view espoused by several authors is that conservative management should be trailed initially, with surgery reserved for patients whose pain persists, or in case of diagnostic uncertainty [1],[9],[11],[12]. Notwithstanding this, Raghavendran et al. reported success and resolution of pain following upfront varicocelectomy in their patient, though larger cohort studies comparing conservative versus surgical management are required to inform future treatment protocols [11].

Thrombosed testicular varicoceles are a rare clinical phenomena and cause of acute scrotal or groin pain but should be considered once testicular torsion and epididymo-orchitis are excluded. Our case adds to the body of literature describing this pathology and serves to aid clinicians in differentiating causes for acute scrotal and groin pain. Important in our case was the reliance on clinical examination to distinguish a scrotal pathology from a radiologically proven but clinically asymptomatic indirect inguinal hernia.