What is the cause of this man’s groin pain?

A 30-year-old male presented to the ED with 24 hours of right testicular pain. He reported that was kicked in the groin 24 hours prior to arrival. Since that time, there had been progressive pain and swelling. He denied dysuria, hematuria, or penile discharge.

 

Physical exam revealed diffuse tenderness and edema of the right testicle and a normal left testicle.

 

The ED team taking care of the patient decided to perform a point-of-care testicular ultrasound to help determine the etiology of his pain.

 

We prefer a systematic approach to testicular ultrasound so that things are not missed. First, both testicles are scanned through using B-mode gray scale imaging.

 

This is the image that was obtained of the right testicle:

 

 You can see that the testicle looks generally normal in size. There is no obvious fracture present. There is no hydrocele. There is a tubular structure intermittently seen in the clip outside of the testicle, but we will get back to that later.

 

Next, flow by color Doppler imaging is performed. We typically like to get both testicles in the same plane so that they can be better compared. In this case, this was unable to be done because of the swelling. Here, only the right testicle is shown, but both were visualized and had symmetric appearing flow.

 

 You can see that color Doppler flow is present.

 

Pulsed-wave Doppler imaging is then performed. Only the right (affected side) is shown below:

 

 You can see that the patient has a normal low-resistance arterial waveform present making torsion unlikely. To be sure, however, we also like to see a venous waveform, as venous waveform might be the only thing absent in early torsion.

 

 You can see this patient also had a venous waveform present, ruling out torsion as a cause of the ongoing pain.

 

The epididymis was then assessed with color Doppler flow.

 

 The epididymis is seen just to the left of the testicle in this image. You can see that the flow to the epididymis is very similar to that of the testicle, which is normal. If the flow was increased or hyperemic, that would be indicative of epididymitis.

 

Finally, we come back to the tubular structure that we saw before.

 

 This has the appearance of a varicocele. See the multiple veins that appear dilated. The sonographer wanted to be sure of this diagnosis so color Doppler was put over the area in question. The patient was then asked to perform a valsalva maneuver and this is what happened:

 

 You can see that with valsalva maneuvers, the flow increases greatly. This is representative of reversal of flow with valsalva maneuver. This in conjunction with the dilated vessels is diagnostic of a varicocele. This gentleman had a diagnosis from bedside ultrasound within minutes of arriving to the ED.

This case demonstrates that as with many things in medicine, histories can be misleading. The varicocele was not thought to be caused by this man’s trauma, but was ultimately found to be the etiology of his pain and edema. This case also demonstrates how quickly and easily testicular ultrasound can be used in the ED to rule in and out a multitude of pathologies very rapidly.

 

Learning Points: 

The most widely accepted diagnostic criteria for varicocele are:

1. Presence of multiple dilated veins (>3.0-3.5mm in diameter)
2. Reversal of flow on color Doppler imaging with valsalva maneuvers