A 4-year-old boy is brought to the clinic for evaluation of scrotal swelling. His mother first noticed swelling near his right testicle after giving him a bath 2 days ago. It has not been painful, and the patient has had no difficulty urinating. Neither the mother nor the patient recalls specific trauma to the area. The patient is otherwise healthy and takes no medications. Temperature is 37.1 C (98.8 F). Initial blood pressure is 160/96 mm Hg; a repeat assessment is 158/92 mm Hg. Physical examination shows an alert child who is active and cooperative. The abdomen is nontender, and bowel sounds are present. Genitourinary examination reveals Tanner stage 1 development with bilateral testicles within the scrotum. There is a palpable, nontender, soft, coiled mass superior to the right testicle. When a light is placed at the base of the scrotum, the mass does not transilluminate. In addition, the mass does not decrease in size when the patient is supine. Urinalysis reveals no blood, nitrites, or leukocyte esterase. Which of the following is the best next step in management of this patient?

Question

A 4-year-old boy is brought to the clinic for evaluation of scrotal swelling.  His mother first noticed swelling near his right testicle after giving him a bath 2 days ago.  It has not been painful, and the patient has had no difficulty urinating.  Neither the mother nor the patient recalls specific trauma to the area.  The patient is otherwise healthy and takes no medications.  Temperature is 37.1 C (98.8 F).  Initial blood pressure is 160/96 mm Hg; a repeat assessment is 158/92 mm Hg.  Physical examination shows an alert child who is active and cooperative.  The abdomen is nontender, and bowel sounds are present.  Genitourinary examination reveals Tanner stage 1 development with bilateral testicles within the scrotum.  There is a palpable, nontender, soft, coiled mass superior to the right testicle.  When a light is placed at the base of the scrotum, the mass does not transilluminate.  In addition, the mass does not decrease in size when the patient is supine.  Urinalysis reveals no blood, nitrites, or leukocyte esterase.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d961_e10f_bc81_9f3d80abd0d6_MD0003_00 This patient's painless, coiled ("bag of worms") scrotal mass that does not transilluminate is most consistent with a varicocele, a dilation of the pampiniform plexus surrounding the spermatic cord and testis. Most varicoceles are primary/idiopathic due to compression of the left renal vein (which drains the spermatic [gonadal] vein) between the superior mesenteric artery and aorta. Increased pressure in the spermatic vein leads to retrograde blood flow, incompetent valves within the vein, and venous dilation. Typical presentation of a primary varicocele is an irregular, left-sided scrotal mass in an adolescent or adult patient that increases with standing/Valsalva maneuver and decompresses in the supine position. primary/idiopathic In contrast, a varicocele that is secondary to venous thrombus or extrinsic compression of the inferior vena cava (IVC) by an abdominal mass (eg, renal or retroperitoneal tumor) is less common but should be considered in the following circumstances: Prepubertal boy Right-sided mass Mass that fails to decrease in size when supine This 4-year-old patient has hypertension and a right-sided varicocele that does not decompress when supine. These findings are concerning for IVC compression by a fixed mass, such as Wilms tumor (the most common renal tumor in children). Therefore, in this patient, the next step in management is an abdominal ultrasound to assess for a secondary cause. (Choices A and C) Testicular cancer typically presents in patients age 15-35 with a painless, firm testicular mass. Initial management includes surgical orchiectomy; biopsy is avoided due to risk of tumor seeding. This patient with a soft, coiled mass has a varicocele; biopsy and orchiectomy are not indicated in its management. (Choice B) Primary, asymptomatic varicoceles in adolescents are often managed with reassurance and observation. A varicocele in a prepubertal patient that persists in the recumbent position, as seen in this patient, warrants evaluation for a secondary cause. (Choice E) Urine culture is included in the evaluation of epididymitis, an infectious cause of scrotal swelling and pain. This patient's scrotal mass is nontender and urinalysis is normal, making epididymitis unlikely. Educational objective: A secondary varicocele should be suspected in a prepubertal boy with a soft, coiled ("bag of worms"), right-sided scrotal mass that fails to decompress when supine. Abdominal ultrasound is indicated to evaluate for anatomical causes leading to venous compression (such as a venous thrombus or abdominal mass). References: Wilm's tumor presenting with scrotal varicocele in an 11-month-old boy. (http://www.ncbi.nlm.nih.gov/pubmed/30050251)

A 4-Year-Old Boy Is Brought to the Clinic for Evaluation