Urology/Dull ache in scrotum
Brief history, 30 y/o male, 5'7 200 lbs. Doppler ultrasound of the Testicles showed varicole on left side, very small hydrocele. I felt a small bump behind my Right testicle, right where the epidydimis meets the testicle in the middle part of the testicle, but they didnt not mention anything about that in my report. Not sure if its relevant as I had it for 2 years and no change of size is noted. I had a left Varicocelectomy back in 2010 where they tied off 3 veins. Diagnosed with Hydrogonatric(?) Hypogonadism a year later.
My issue today is that I have been having this dull ache in my scrotum area. I do not notice any lumps on testicle. I notice a little bit of fluid build up on my left side again, in which I used a flash light to check for transillumination, in which it lit up red, meaning more than likley a hydrocele came back, plus it feels soft and fluidy. I also notice when when I felt my spermatic cord, that I noticed the vein pop out on the left side. I feel that the Varicocele came back. What are the reoccurance rate fo these? I just notice that my scrotum is more loser and that my testicles sag a little more than usual(When penis is flacid, you can see the testicles well).
I do not have any burning upon urination, no discharge. I checked for a Hernia, and I cant feel any types of swelling in the Inguinal area.
With that being said, what would be the next course of action? (I do work in the medical field as a Hospital Corpsman in the US Navy)
Scott, you need to see a urologist in consultation so that a definitive diagnosis can be made. It sound like you have a recurrent varicocele and hydrocele. The small "bump" behind the right testicle is probably just a benign . lesions such as a tunica albuginea or epididymal cyst. Lesions less than 2-3 mm in size usually are too small to be detected on ultrasound. As I have written extensively on each of the subjects, I will attach my "macro" on each to give you further information and advise.
VARICOCELE: A varicocele is a collection of varicose veins of the spermatic cord (the rope-like structure that suspends each testicle). They occur in about 15% of the population. More than 90% occur on the left, 5% on the right and the rest are bilateral. Varicoceles are due to a defective valve in the vein that drains blood from the testicle. They fill by gravity and, therefore, are not detectable while recumbent but apparent when upright. They may be more pronounced with coughing, straining or sexual arousal. On examination, the lesion feels like a bag of worms. Small varicoceles may only be detected by imaging studies such as ultrasound. A varicocele that does not disappear when lying down may indicate a tumor in the abdomen (but this is quite unusual). Varicoceles are generally painless. Often men present to the doctor with pain in the testicle and the varicocele is discovered at that time. In my experience, the pain is infrequently due to the varicocele and usually due to prostatitis (an inflammation of the prostate gland). In other words, the varicocele is often an incidental and unrelated condition. Other urologists, however, state that varicoceles can cause pain and that the pain is relieved by varicocelectomy in about 85% of cases. However, surgery for relief of this type pain alone is usually a last resort treatment.
Varcioceles may cause an infertility problem manifest by lower sperm counts and increased numbers of immature sperm in the semen on analysis. However, the majority of men with varicoceles do NOT have infertility. Of men who have abnormal semen analyses and varicoceles, in about 70% of them, the 2 are related and fixing the varicolele often will improve their fertility. The mean testosterone concentration of men older than 30 years of age with varicoceles was significantly lower than that of younger patients with varicoceles whereas this trend was not seen in men without varicoceles. Repairing varicoceles appears to improve serum testosterone levels in most, but not in all men. These findings indicate that varicoceles result in abnormal Leydig cell function (the testicular cells that produce testosterone) in some men, but these patients may also be the ones to most benefit from surgical repair. Various studies cite the improvement in serum testosterone from 30-90%, most being in the 30-40% range.
If a teenager or young men with a varicocele has a smaller than normal testicles on that side, there is an increase risk of infertility and many urologists consider this an indication to fix the varicocele surgically. Other than for infertility, there are just a few indications for repairing a varicocele. They can be fixed for cosmetic reasons or because they become too weighty. There are several types of varicocele repair, but they all have in common occluding the vesssels supply in the varicocele rather than actually removing the veins. This prevents blood from filling the varicocele. Such techniques include formal open surgery, microsurgery, laparoscopic repair and venous embolization. As with any procedure there are potential complications. These may include persistence of the varicocele, hematoma, hydrocele, damage to the ilioinguinal nerve and occasionally damage to the arterial supply of the testicle. Because their is an accessory blood supply to the testes, there is controversy as to whether or not this definitively results in atrophy of the testis.
To be sure about the diagnosis and get recommendations options for treatment (or not), consultation with a urologist is suggested.
HYDROCELE: Surrounding the testicle is a thin layer of tissue folded upon itself with a potential (but empty) space between these leaves. This membrane is called the tunica vaginalis. The cells of the inner lining of this membrane have the potential to secrete fluid in response to trauma, allergies, infections, local tumors, etc. If fluid is produced, the space becomes filled as the walls of the membrane separate more from each other. This is called a simple hydrocele. It is a perfectly benign condition and requires no treatment. There are 2 exceptions:
1. If there is an associated tumor of the testicle that stimulated the hydrocele to form. It is, therefore, important to establish that the associated testicle is normal either by physical examination or ultrasound of the scrotum. One simple test is to hold a flash light against the scrotum. Hydroceles transilluminate (let light pass through) whereas solid masses do not. If there is any question about the diagnosis, it can be confirmed on an ultrasound of the scrotum.
2. If there is a hernia that is contiguous with the hydrocele. This is called a "communicating hydrocele" and requires repair via an inguinal (groin) as opposed to a trans-scrotal approach for a simple hydrocele. Typically these hydroceles are smaller in the morning after lying in bed at night and enlarge during the day as the they fill by gravity from the normal fluid inside of the abdominal cavity.
Generally, there is no pain with a simple hydrocele, just a local heaviness because of the increased weight of the lesion. Hydroceles can be treated either for cosmetic reason or because of increased weight and local anatomic distortion and bulging. The traditional treatment is surgical excision which is generally done on an outpatient basis. Usually the discomfort is gone by 1-2 weeks and normal activity can be resumed shortly thereafter. However, there is often residual swelling that gradually subsides over 2-4 months. Another treatment method used widely in Europe and somewhat in the USA, is needle aspiration of the fluid followed by the injection of a sclerosing agent (such as 2.5% phenol) . The latter damages the secreting cells in an effort to prevent reaccumulation. Aspiration alone provides only temporary relief as the fluid always recurs over time. Each repeated aspiration increases the risk of introducing infection into the hydrocele and is, therefore, not considered a good alternative for definitive care. Again, no treatment is necessary for a simple benign hydrocele.
SCROTAL LUMPS: In evaluating lumps inside the scrotum, it is important to differentiate those that are extra-testicular, (originating from the contents of the scrotum but not actually from the testicle) from those that are originating from the testicle per se. The former are very common and almost always benign. Such examples would include hernia, varicocele, epididymal cyst, spermatocele, hydrocele, etc. Inflammation of the epididymis (epididymitis) typically produces a mass in this structure that gradually recedes as healing occurs. After a vasectomy, a small, sensitive mass can develop at the site of surgery called a spermatic granuloma. There also exists a small embryonic remnant on the upper pole and the testicle and another on the head of the epididymis. These are called the appendix testis (also know as the hydatid of Morgagni) and the appendix epididymis respectively. None of the requires treatment and they are generally painless. The one exception is that occasionally the appendix can twist (torsion) and shut off its blood supply. This produces a painful nodule that gradually disappears in a week or so. Sometimes they are removed surgically if one cannot differentiate them from torsion of the testicle.
Testicular lesions can also be benign, the most common of these being a tunica albuginea cyst which characteristically is smooth, round, painless and rarely more than 5mm in size. All other masses of the testicle are to be considered tumor until proven otherwise. A urologist can usually differentiate between the various lesions on physical examination. An ultrasound of the scrotum will generally be done if the diagnosis is not obvious or there is concern about tumor.
Since the evaluation of scrotal lumps by a layman can be difficult & inaccurate, it is my advice to consult with a urologist. Good luck.