A varicocele is an external manifestation of a collection of dilated and tortuous spermatic veins (see Figs. 12.3 and 12.4). It is thought that this is a result of increased hydrostatic pressure of incompetent valves in the testicular venous system resulting in reflux [25]. Most varicoceles are left sided, due to right angle insertion of the left testicular vein into the left renal vein [26]. The overall incidence of varicocele in the healthy male population is between 10 and 15 % and typically appears soon after puberty [27]. The clinical importance of a varicocele is its association with infertility, but the impact of varicocele on fertility and the benefits of treatment remain controversial [26].

Males with varicocele are often asymptomatic and it is recognized on routine physical examination [27].

The patient should first be examined in the standing position so that the examiner can inspect the scrotum [27]. On palpation a varicocele has been classically described as a “bag of worms” but may also feel like a thickened, asymmetric cord if it is subtle [27]. There are various grades of varicocele that can be distinguished:

An ultrasound of the scrotum is a widely used test to assess for a varicocele [25]. In men with varicoceles and an abnormal semen analysis, it is recommended that an endocrine work-up be performed with serum testosterone and follicle-stimulating hormone (FSH) levels [26]. Furthermore, a referral should be made to a urologist and/or reproductive endocrine and infertility specialist.

There are many available treatment modalities for varicoceles, and they depend on the severity of the varicocele. There are a variety of operative and nonoperative techniques such as percutaneous radiological, open surgical, laparoscopic, and microsurgical techniques. The goal of the surgery is to ligate the veins contributing to the varicocele formation while at the same time leaving some veins patent to drain [25]. Interestingly, a 2001 Cochrane review of the effect of varicocelectomy or embolization on fertility was inconclusive [26].

On physical exam, spermatoceles and epididymal cysts usually feel smooth, soft, well-circumscribed, and transilluminate (see Fig. 12.5). Failure to transilluminate suggests a solid lesion, which warrants further evaluation, including scrotal ultrasonography and possible inguinal exploration [30]. Spermatoceles and epididymal cysts are palpated as distinct from the testis, which differentiates them from hydroceles and testicular cancer.

Spermatoceles and epididymal cysts are often easily differentiated from other scrotal pathology based on history and exam. However, if there is uncertainty, they can be diagnosed by scrotal ultrasonography [30].

Treatment of spermatoceles and epididymal cysts is typically reassurance and surveillance. Occasionally, patients require surgical excision for chronic pain related to a spermatocele.

Idiopathic hydroceles are the most common type of hydrocele and usually arise over a significant period of time. Idiopathic hydroceles are often asymptomatic, despite considerable scrotal enlargement. Other conditions such as inflammatory disorders of the scrotum (e.g., epididymitis, torsion, appendiceal torsion), trauma, and testicular cancer can produce an acute reactive hydrocele, which often resolves with treatment or resolution of the underlying condition [31]. Conditions resulting in generalized edema such as protein losing enteropathy, hepatic cirrhosis, and nephrotic syndrome can also cause a hydrocele.

Patients with hydroceles often present with a painless swelling or mass which may appear unilateral or bilateral in the scrotum. Patients may also report a sensation of heaviness in the scrotum. Significant discomfort should alert the clinician to consider a reactive hydrocele from another cause.

Examination of patients with hydroceles should include palpation of the entire testicular surface for findings of epididymal tenderness, testicular torsion, trauma, or mass/tumor as the primary etiology [33]. Hydrocele fluid in the scrotal sac transilluminates well, which differentiates the process from hematocele, hernia, or solid mass (see Fig. 12.6). A hydrocele that communicates with the peritoneal cavity may increase in size with the Valsalva maneuver. Hydroceles discovered in infancy are usually communicating and usually disappear in the recumbent position, and an indirect hernia is often appreciated on exam. Communicating hydroceles are usually reducible, while noncommunicating hydroceles are not reducible.

The diagnosis of hydrocele can be made by physical examination and transillumination of the scrotum demonstrating a cystic fluid collection. A scrotal ultrasound should be performed if the diagnosis is in question since a reactive hydrocele can occur in the presence of a testicular neoplasm or with acute inflammatory scrotal conditions.

In adults, no therapy is needed unless the hydrocele causes discomfort and compromises scrotal skin integrity from chronic irritation or if there is an underlying cause that required treatment [31, 34]. The management of hydrocele in a neonate or child younger than 1 year of age usually is supportive [31]. In children, surgical repair is indicated for hydroceles in newborns that persist beyond 1 year of age, for communicating hydroceles, and for other symptomatic hydroceles that are enlarging [31]. Reactive hydroceles usually resolve with treatment of the underlying condition. If surgical repair is required, the most common treatment is surgical excision of the hydrocele sac. Simple aspiration of a hydrocele is generally unsuccessful due to rapid re-accumulation of fluid.

Communicating hydroceles in older men rarely resolve and pose a risk for the development of an incarcerated inguinal hernia [31, 33, 34].

There are a number of known risk factors for testicular neoplasia, including cryptorchidism, a personal or family history of testicular cancer, infertility or subfertility, hypospadias, white males, family history, and HIV infection [41–45]. Studies investigating the contribution of prenatal and later environmental exposures, such as endocrine disruptors and estrogen/antiandrogen components, to testicular cancer risk have yielded inconsistent results [42, 46]. It has been suggested that vasectomy may increase the risk of testicular cancer, but data does not support this association [47]. Men who are at high risk for testicular cancer should consider regular testicular exams with a healthcare provider and self-examination. However, the US Preventive Services Task Force (USPSTF) recommends against testicular cancer screening in the general population [48]. This recommendation is based on inadequate evidence that screening asymptomatic patients by means of self-examination or clinician examination has greater yield or accuracy for detecting testicular cancer at more curable stages and potential harms of false-positive results, anxiety, and harms from diagnostic tests or procedures. The USPSTF notes, “Screening by self-examination or clinician examination is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer” [48].

Testicular cancer usually presents as a painless mass discovered by the patient or clinician on physical examination. However, in approximately 10 % of cases, rapidly growing germ cell tumors may cause acute scrotal pain secondary to hemorrhage and infarction. Other presenting symptoms include testicular firmness, swelling, an aching in the lower abdomen, and scrotal heaviness. In approximately 10 % of cases, the presenting manifestations of testicular cancer are attributable to metastatic disease including gynecomastia, gastrointestinal symptoms such as dull abdominal pain that can radiate to the groin area, or respiratory symptoms such as cough, chest pain, and shortness of breath [38, 49]. Rare presentations include those of Leydig cell tumors, which account for 2 % of testicular tumors and have a clinical presentation dominated by symptoms of excess estrogen and reduced testosterone such as gynecomastia, breast tenderness, fatigue, and decreased sexual drive. Sertoli cell tumors are even less common and also present with symptoms of excess estrogen [38].

The initial evaluation of a man with a suspected testicular tumor should include a detailed and thorough physical examination of the scrotum. Small, benign calcifications on the surface of the testis are relatively commonly detected on physical examination and are not cause for alarm but should be well documented and followed on repeat examinations to document stability. Intrascrotal malignancies are usually firm, non-tender, nonmobile masses that do not transilluminate, although a reactive hydrocele may be evident with transillumination (see Fig. 12.7). Some patients may have accompanying gynecomastia resulting from excess estrogen production with various tumors.