On physical examination, hydroceles can range from not palpable to grapefruit size and larger; consistency varies from firm to soft. Typically painless, hydroceles can feel heavy and may cause discomfort when bumped or squeezed. As cystic structures, they will transilluminate well unless the tunica vaginalis wall is too thick. US will help with diagnosis; more important, it can assess the underlying testicle, which may not be palpable on physical examination.9

Treatment options include no treatment at all if the lesion is not bothersome for the patient. Surgical treatment involves removal or inversion of the tunica vaginalis so that fluid is not trapped in the pouch. Aspiration of a hydrocele will effectively reduce its size. However, the defect that caused the swelling and the compartment that houses it will remain, and the hydrocele will refill as quickly as the fluid is formed. Aspiration, therefore, is not an adequate treatment option.

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About 15% of all men will have a varicocele,9 and 40% of subfertile men are found to have a varicocele, which is defined as dilated, tortuous veins within the pampiniform plexus of the spermatic vein.2 A simpler description is varicose veins in the scrotum. A typical vein in the pampiniform plexus measures 0.5 mm to 1.5 mm; in a palpable varicocele, the veins can get as large as 5 mm to 6 mm.10 The lesion rarely develops before puberty. It is found by the patient, by the clinician at physical examination, or incidentally on US of the scrotum. Varicoceles are graded based on visual examination and palpability (Table 1). 

Generally, varicoceles are painless, but some patients will describe an achy, heavy sensation in the scrotum, especially with performance of a Valsalva maneuver or physical activity. On physical examination, the lesion, when visible, is described as “a bag of worms” that is appreciated proximally and anterior to the testicle. Additionally, especially in teenagers who are still growing, the ipsilateral testicle may be smaller. Repair of the varicocele may allow the atrophied testicle to catch up in growth.11 The varicocele will disappear temporarily when the patient is prone and the scrotum is elevated. If the lesion remains visible, further evaluation is warranted for pelvic pathology.

Although varicoceles are occasionally found bilaterally, these lesions are most commonly found on the left side for reasons that are not completely understood. One hypothesis stems from the fact that compared with the right spermatic vein, the left spermatic vein is about 8 cm to 10 cm longer, and it drains at a right angle into the left renal vein. This causes more resistance than is found on the right side, where drainage is directly into the vena cava. A second, less common, factor is that some men have compression of the renal vein, which causes increased resistance in addition to that generated in the left spermatic vein.11 The compression of the left renal vein occurs as it passes between the aorta and the superior mesenteric artery. This condition is often referred to as “the nutcracker phenomenon.”

The reason for decreased fertility is not conclusive, but once again, there are reasonable hypotheses to consider. The first is that pooling of blood in the pampiniform plexus increases the temperature in the scrotum. Testicles are positioned outside the body (in the scrotum) because spermatogenesis is most effective at a temperature lower than 37°C. Pituitary-gonadal hormone dysfunction and internal spermatic vein reflux are other possible causes. All three problems are likely to contribute in varying degrees to infertility.1

Indications for treatment include infertility, atrophy of the ipsilateral testicle and pain that can reasonably be attributed to the varicocele. Varicocele repair will improve fertility in 70% of subfertile patients.3 Noted improvement on semen analysis includes increased sperm count and greater sperm motility. Treatment is usually a urologic surgical repair, in which a suprapubic incision is made and the pampiniform plexus is tied off. An interventional radiologist can repair a varicocele with embolization of the spermatic vein. A surgical procedure is generally the initial treatment since fertility and testicular health are a significant part of the workup and treatment of a varicocele. Interventional radiology (embolization) is most often utilized if surgical repair does not correct the lesion.


Inflammation in the epididymis (i.e., epididymitis) can progress and involve the testicle. Epididymitis is generally an infectious process that can be either sexually transmitted or the result of a urinary tract pathogen, primarily Escherichia coli. In almost all cases, bacteria migrate through the urethral meatus into the bladder and are forced retrograde through the vas deferens into the epididymis as a result of straining with physical activity or lifting.

The rule of thumb is that epididymitis in a patient younger than age 35 years is more likely to be associated with a sexually transmitted infection, whereas epididymitis a patient older than age 35 years is most likely caused by a urinary tract infection (UTI).12 However, many cases of epididymitis are not infectious but rather are caused by an idiopathic inflammatory process.