What is the best management approach for an elderly man with Congestive Heart Failure (CHF) and scrotal ultrasound findings of bilateral epididymal cysts, a large complex left hydrocele, and a right-sided varicocele?

Management of Scrotal Findings in an Elderly CHF Patient

Conservative management with optimization of heart failure therapy is the appropriate approach for this elderly patient with CHF and incidental scrotal findings, as none of the ultrasound findings (bilateral epididymal cysts, complex hydrocele, or right varicocele) require urgent intervention in the absence of acute pain, testicular torsion concern, or suspicion for malignancy. 1, 2

Immediate Assessment Priorities

Volume Status Evaluation

• Assess for CHF-related scrotal edema by examining for bilateral lower extremity edema, jugular venous distension, hepatojugular reflux, pulmonary rales, and S3 gallop, as volume overload from CHF commonly causes bilateral scrotal swelling and discomfort (though not acute severe pain). 1, 2, 3
• Monitor daily weights and strict intake/output to guide diuretic therapy optimization. 3
• Check orthostatic blood pressures to evaluate volume status and guide fluid management. 2, 3

Exclude Urgent Pathology

• The complex left hydrocele warrants attention because any solid component within a hydrocele raises concern for underlying testicular malignancy or rare entities like mesothelioma of the tunica vaginalis. 4
• However, in the absence of a palpable testicular mass, acute pain, or systemic symptoms, urgent surgical exploration is not indicated. 5
• The right-sided varicocele is unusual (left-sided predominates due to venous anatomy) and could theoretically represent venous obstruction from increased central venous pressure in CHF, though this is uncommon. 6

CHF Optimization as Primary Management

Diuretic Therapy

• Initiate or optimize loop diuretics (furosemide) to achieve euvolemic state, as scrotal edema and hydrocele accumulation may be exacerbated by volume overload. 5, 3
• Monitor renal function (BUN, creatinine) and electrolytes (potassium, magnesium) closely during diuresis, particularly in elderly patients who are at higher risk for renal dysfunction. 5, 3

Medication Review

• Review current CHF medications for potential effects on scrotal pathology, though none typically cause acute testicular issues. 1
• Ensure the patient is on guideline-directed medical therapy including ACE inhibitors (or ARBs if ACE-intolerant), beta-blockers, and consider aldosterone antagonists if appropriate for NYHA class. 5
• In elderly patients, use cautious dose titration due to altered pharmacokinetics and increased risk of hypotension and renal dysfunction. 5

Management of Specific Scrotal Findings

Bilateral Epididymal Cysts

• Epididymal cysts are benign and require no intervention unless symptomatic (causing pain or significant discomfort). 6, 7, 8
• If future intervention is desired for symptomatic relief, sclerotherapy with polidocanol or tetracycline offers cure rates of 64-87% with low complication rates, though this is not indicated currently. 7, 8

Large Complex Left Hydrocele

• The "complex" nature requires clarification: if this represents septations or debris only, conservative management is appropriate; if solid nodular components are present, further evaluation is needed. 4
• In the absence of testicular mass on physical exam or ultrasound, and given the patient's CHF comorbidity, watchful waiting with repeat scrotal ultrasound in 6-8 weeks after CHF optimization is reasonable to determine if the hydrocele decreases with improved volume status. 5, 1
• Surgical intervention (hydrocelectomy) should be deferred unless the hydrocele causes significant discomfort, functional impairment, or grows despite CHF optimization. 6, 4
• Critical pitfall: Complex hydroceles can rarely harbor malignant mesothelioma of the tunica vaginalis, which is often diagnosed incidentally during hydrocele surgery, so any solid components warrant close follow-up. 4

Right-Sided Varicocele

• Right-sided varicoceles are less common and may indicate increased central venous pressure from CHF rather than primary testicular pathology. 1, 6
• In an elderly patient with CHF, varicocele repair is not indicated unless associated with testicular atrophy, pain, or fertility concerns (unlikely relevant in this population). 6
• Reassess after CHF optimization, as improved hemodynamics may reduce varicocele prominence. 1

Follow-Up Strategy

Short-Term (2-3 Months)

• Optimize CHF therapy to euvolemic state and reassess scrotal findings clinically. 1, 3
• Repeat scrotal ultrasound in 6-8 weeks if the complex hydrocele persists or if any new symptoms develop (pain, enlargement, palpable mass). 5
• Monitor renal function and electrolytes during diuretic optimization. 5, 3

Long-Term Surveillance

• Annual clinical scrotal examination is reasonable given the complex hydrocele finding. 5, 4
• Educate the patient to report any new testicular pain, rapid enlargement, or palpable masses immediately. 5

When to Consider Surgical Referral

Surgical consultation with urology is indicated if:

• A solid testicular mass is identified on repeat imaging. 5
• The complex hydrocele demonstrates solid nodular components concerning for malignancy. 4
• Progressive symptomatic enlargement occurs despite CHF optimization. 6, 4
• Acute scrotal pain develops (concern for torsion, though rare in elderly). 5

Surgical intervention can be performed via single scrotal access for bilateral pathology if needed, with low complication rates even in patients with comorbidities, though this should be deferred until CHF is optimized. 6