Thrombosed varicocele - a rare cause for acute scrotal pain: a case report

Spontaneous bilateral pampiniform plexus thrombosis in a teenager

Spontaneous pampiniform plexus thrombosis is an extremely rare condition. Its aetiology and pathophysiology are unknown, and its diagnosis remains challenging. We present the first case of an adolescent patient with bilateral spontaneous pampiniform plexus thrombosis. He presented with a 2-day history of bilateral testicular pain. Biochemical investigations were unremarkable, and the patient did not have any risk factors. Ultrasound of the scrotum demonstrated bilateral pampiniform plexus thrombosis. He was managed conservatively and repeat scrotal ultrasound 3 months later revealed complete resolution. This case adds to the minimal literature on spontaneous pampiniform plexus thrombosis, supporting diagnosis via scrotal ultrasound while recommending conservative management without the use of anticoagulation for patients with no pre-existing coagulopathy.

Unusual Case of Left Testicular Pain Due to Pampiniform Venous Plexus Thrombosis: A Case Report

Spontaneous thrombosis of the pampiniform venous plexus is a rare phenomenon, with limited cases reported in the literature. Accurate diagnosis necessitates a high index of suspicion, and scrotal Doppler ultrasound proves to be an effective diagnostic tool. This case report aims to elucidate the diagnostic intricacies of spontaneous thrombosis of the left pampiniform venous plexus, emphasizing the pivotal role of scrotal Doppler ultrasound. Additionally, we explore successful treatment modalities, including anticoagulation and bed rest, leading to complete resolution. This contribution aims to enhance clinical understanding, particularly in outpatient and emergency care settings, where accurate and timely diagnosis is imperative.

Surgical management of chronic scrotal pain: a review of the current literature

Chronic scrotal pain may be due to an identifiable cause, may be multifactorial, or may be idiopathic. Successful treatment often requires multimodal therapy with a multidisciplinary approach. Conservative options may be offered initially, but if symptoms fail to improve with conservative interventions, more invasive therapies may be required. A nerve block may be attempted and patients who experience improvement in pain following nerve blocks may be good candidates for surgical denervation of the spermatic cord. Alternative surgical treatment options including proximal nerve blocks, neuromodulation, cryoablation, vasectomy reversal, varicocelectomy, and even orchiectomy have been described. The aim of this review is to discuss the treatment options for chronic scrotal pain with a focus on surgical treatment options.

Trombosis de la vena espermática derecha. Primer caso clínico reportado en Colombia

Introducción. La trombosis de la vena espermática (TVE) es una entidad muy poco frecuente de la cual no se tienen datos epidemiológicos específicos. Su presentación es de predominio izquierdo, en la mayoría de los casos su causa es desconocida y su diagnóstico suele realizarse por exclusión en el estudio del escroto agudo. A continuación, se presenta el primer caso documentado de TVE en Colombia y uno de los pocos de lateralidad derecha en el mundo. Presentación del caso. Hombre de 21 años quien consultó al servicio de urgencias de una institución de tercer nivel de atención de Bogotá, Colombia, por un cuadro clínico de una semana de evolución consistente en dolor en región inguinoescrotal derecha que aumentó progresivamente de intensidad y estuvo acompañado de un pico febril no cuantificado; el paciente indicó como único antecedente médico un trauma craneoencefálico leve sin secuelas a los 20 años. Se realizó estudio con ecografía Doppler testicular en donde se observó trombosis del cordón espermático derecho. Se inició manejó con antibioticoterapia, heparinas de bajo peso molecular y cumarínicos, con lo cual se obtuvo una adecuada respuesta y la resolución del cuadro. Conclusión. La TVE representa un reto diagnóstico, por lo que se requiere de una alta sospecha clínica, la cual se genera teniendo conocimiento de la entidad e incluyéndola en el diagnóstico diferencial del escroto agudo. La ecografía Doppler es una herramienta fundamental para diagnosticar TVE, además permite iniciar un tratamiento conservador oportuno, seguro y eficaz que evite desenlaces desfavorables para el paciente, lo que resulta ser costo-efectivo.

Contribution of pre-varicocelectomy color Doppler ultrasonography finding to surgery and its correlation with semen parameters

BACKGROUND

This study aimed to determine the contribution of color Doppler ultrasonography (CDUS) performed before varicocelectomy to the success of surgical treatment and to evaluate the correlation between CDUS findings and semen parameters.

METHODS

A total of 84 patients diagnosed with grade 3 left varicocele in our clinic between 2016 and 2018 were evaluated. The patients in whom the decision for varicocelectomy was based on only physical examination (PE) findings and abnormal semen analysis (SA) were defined as Group 1, while the patients undergoing varicocelectomy based on PE, CDUS and SA findings were defined as Group 2. The patients diagnosed with varicocele based on PE and CDUS findings who were included in a followup protocol due to normal semen parameters were defined as Group 3.

RESULTS

In Group 1, there was a total of 28 patients and the mean number of ligated internal spermatic veins was 4.53 (range, 2-10). In Group 2, there was a total of 30 patients and the number of ligated internal spermatic veins was 3.76 (range, 1-8). No statistically significant difference was found between Group 1 and 2 in terms of the number of internal spermatic veins ligated during varicocelectomy. No statistically significant correlation was found between semen parameters and the number of veins ligated during varicocelectomy in Group 1 and 2 and between semen parameters and CDUS findings group 2 and 3.

CONCLUSIONS

In patients with primary grade 3 varicocele, diagnosed by physical examination there is no need for additional imaging in primary cases.

What is beyond testicular torsion and epididymitis? Rare differential diagnoses of acute scrotal pain in adults: A systematic review

Background

Acute scrotal pain is a urological emergency. While for testicular torsion and acute epididymitis clinical recommendations are well established, few is known about low incidence causes of acute scrotal pain. Our aim is to identify and characterise rare differential diagnoses of acute scrotal pain in order to give diagnostic and therapeutic recommendations.

Materials and methods

A systematic literature search was performed in PubMed, Web of Science and the Cochrane Library databases up to February 2019 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The systematic review protocol was registered on PROSPERO (CRD42018099472).

Results

Eighty-four publications were selected for analysis. The databases provided mostly case reports, series and small studies, overall reporting on a cohort of 245 cases. Tumors, segmental testicular infarction, testicular vasculitis, pancreatitis, brucellosis, spermatic vein thrombosis, acute aortic syndrome and appendicitis were identified as rare underlying causes of acute scrotal pain and were characterised. As a result of our data analysis we were able to draw an overview of the rare differential diagnoses and diagnostic management of acute scrotal pain.

Conclusion

Rare differential diagnoses of acute scrotal pain are susceptible to misinterpretation as testicular torsion or acute epididymo-orchitis. Surgical management is indicated in case of suspicion for torsion or tumor. We herein present knowledge of the rare differential diagnoses and raise awareness for associated systemic disease in order to facilitate disease management and increase the potential for testicle-sparing treatment.

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First systematic approach to assess literature for rare differential diagnoses of acute scrotal pain.

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Disease characterization including sonographic features.

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Flow chart for the diagnostic and treatment options of acute scrotal pain beyond testicular torsion and common epididymo-orchitis.

Challenges in the diagnosis of testicular infarction in the presence of prolonged epididymitis: Three cases report and literature review

INTRODUCTION

Testicular infarction is a rare complication of prolonged epididymitis and may be misdiagnosed as testicular torsion. In this study, we present three cases of testicular infarction and discuss their clinical characteristics, imaging features and clinical management.

PATIENTS AND METHODS

Three adult males with prolonged epididymitis presented with chronic unilateral testicular pain, tenderness, and palpable swelling, including left varicocele in one case and hydrocele in the other two cases. Patient's symptoms were not relieved after antibiotic therapy. We analyzed the diagnosis, management, and outcome of these three cases of testicular infarction resulting from prolonged epididymitis. This includes the clinical characteristics, features of color doppler ultrasound imaging for diagnosis, and treatment strategy for testicular infarction from prolonged epididymitis.

RESULTS

Complete blood count (CBC) indicated a small leukocytosis (10.6±0.4×109/L; normal arrange 3.5-9.5 WBC×109/L). Color doppler images demonstrated appropriate blood flow to areas of interest at patient's initial visit. At follow up visit several months later, the increased blood flow was detected at the edges of the involved testes with no blood flow to the center. The sizes of the involved testis (27±4 ml) was significantly larger compared to the non affected side (17±2 ml) (p < 0.05). Unilateral simple orchiectomy was performed on the involved testis in all three cases. Grossly, abscess cavities with caseous necrosis were found at the center of the testicle and epididymis in two patients. Histopathologic examination showed chronic inflammation with lymphocytic and macrophage infiltration of the involved testicle in two cases. The third case stained positive for acid fast bacteria. Left varicocele disappeared postoperatively in one patient. No pain, wound infection or other discomfort were noted 12 months after surgery.

COMMENTS

This series revealed that testicular infarction may result from inappropriately treated prolonged epididymitis. Epididymal tuberculosis should be considered in cases with epididymitis not responding to broad spectrum antibiotics. Testicular infarction induced by prolonged epididymitis is easily missed due to a lack of symptom changes. Color doppler images are helpful in the diagnosis. This usually presents as a decrease in blood flow at the center of the testis with the increased flow at the periphery differentiating this from testicular torsion.