Figure 1
Figure 1
Longitudinal US scan of the left testis shows intratesticular tubular cystic structures of varying sizes.
Intratesticular varicocele
SectionUroradiology & genital male imaging
Case TypeClinical Cases
AuthorsCiudad MJ, Montes M, Vañó-Galván E, Sánchez-Cabello M.
Connected authors
32 years, male
Clinical History
A 32 year old man consulted for infertility. He referred a history of bilateral cryptorchidsm that required surgical intervention in his childhood.
Imaging Findings
A testicular sonography was performed, which revealed small testis with preserved homogeneous echogenicity. Anechoic lesions were observed in the left testis, many of them tubular and located in the mediastinum. In the colour Doppler scan this tubular structures resulted to have flow, demonstrating its vascular nature. In the duplex Doppler scan, venous flow which increased with Valsalva maneuver was shown. The diagnosis is intratesticular varicocele. No extratesticular varicocele was found in this patient.
Discussion
Benign intratesticular lesions are rare, but recognition is important to avoid unnecessary surgical intervention.
While extratesticular varicocele is a common entity, with a reported prevalence of 8-20% in normal population, intratesticular varicocele is a rare condition. In a large series of 1040 patients examined for suspected varicocele, only 18 (1.7%) had intratesticular varicocele. In non-selected patients, a prevalence of 0.4% has been reported. The pathogenesis is uncertain and its clinical implications remain unknown. Most of the reported cases occur in the left side. Testicular pain is the most common presentation, related to passive congestion of the testis, which eventually stretches the tunica albuginea. Nevertheless, it was not present in our case. The relationship of male infertility to intratesticular varicocele is still to be stablished, moreover if the condition is not bilateral and does not associate to extratesticular varicocele. Intratesticular varicocele is often associated with ipsilateral testicular atrophy, but whether it is a cause or a consequence of testicular atrophy remains unclear.
The US findings of intratesticular varicocele are similar to those of extratesticular varicocele and include multiple anechoic, serpiginous, tubular structures of varying sizes. Colour flow and duplex Doppler US show a venous flow pattern with a characteristic venous spectral waveform, which increases with the Valsalva maneuver. The main differential diagnosis is a pseudoaneurysm, which has a characteristic yin-and-yang flow pattern, distinct from the venous flow of a varicocele. Intratesticular cyst, tubular ectasia of rete testis, hematoma, focal infetion and cystic intratesticular neoplasm may mimic the appearance of intratesticular varicocele. Condition is not bilateral and does not associate to extratesticular varicocele. Nevertheless, its specific sonographic and Doppler appearance should enable the radiologist to obviate further study.
While extratesticular varicocele is a common entity, with a reported prevalence of 8-20% in normal population, intratesticular varicocele is a rare condition. In a large series of 1040 patients examined for suspected varicocele, only 18 (1.7%) had intratesticular varicocele. In non-selected patients, a prevalence of 0.4% has been reported. The pathogenesis is uncertain and its clinical implications remain unknown. Most of the reported cases occur in the left side. Testicular pain is the most common presentation, related to passive congestion of the testis, which eventually stretches the tunica albuginea. Nevertheless, it was not present in our case. The relationship of male infertility to intratesticular varicocele is still to be stablished, moreover if the condition is not bilateral and does not associate to extratesticular varicocele. Intratesticular varicocele is often associated with ipsilateral testicular atrophy, but whether it is a cause or a consequence of testicular atrophy remains unclear.
The US findings of intratesticular varicocele are similar to those of extratesticular varicocele and include multiple anechoic, serpiginous, tubular structures of varying sizes. Colour flow and duplex Doppler US show a venous flow pattern with a characteristic venous spectral waveform, which increases with the Valsalva maneuver. The main differential diagnosis is a pseudoaneurysm, which has a characteristic yin-and-yang flow pattern, distinct from the venous flow of a varicocele. Intratesticular cyst, tubular ectasia of rete testis, hematoma, focal infetion and cystic intratesticular neoplasm may mimic the appearance of intratesticular varicocele. Condition is not bilateral and does not associate to extratesticular varicocele. Nevertheless, its specific sonographic and Doppler appearance should enable the radiologist to obviate further study.
Differential Diagnosis List
Intratesticular varicocele
Final Diagnosis
Intratesticular varicocele
References
[1] Das KM, Prasad K, Szmigielski W, Noorani N (1999) Intratesticular varicocele: evaluation using conventional and Doppler sonography. AJR Am J Roentgenol 173(4):1079-83. (PMID: 10511183)
[2] Dogra VS, Gottlieb RH, Rubens DJ, Liao L (2001) Benign intratesticular cystic lesions: US features. Radiographics 21:S273-81. (PMID: 11598263)
[3] T退treau R, Julian P, Lyonnet D, Rouvi耀re O (2007) Intratesticular varicocele: an easy diagnosis but unclear physiopathologic characteristics. J Ultrasound Med 26(12):1767-73. (PMID: 18029929)
Case information
| URL: | https://www.eurorad.org/case/7652 |
| DOI: | 10.1594/EURORAD/CASE.7652 |
| ISSN: | 1563-4086 |
Figure 2
Figure 2
Color Doppler US scan shows flow within the
tubular structures.
Figure 3
Figure 3
Pulse Doppler US scan shows increased flow with the Valsalva maneuver, a finding characteristic of venous flow. The patient had not any associated extratesticular varicocele (not shown).
Figure 1
Longitudinal US scan of the left testis shows intratesticular tubular cystic structures of varying sizes.
Figure 2
Color Doppler US scan shows flow within the
tubular structures.
Figure 3
Pulse Doppler US scan shows increased flow with the Valsalva maneuver, a finding characteristic of venous flow. The patient had not any associated extratesticular varicocele (not shown).