What could be the cause of testicular pain in a patient with a history of varicose (enlarged or twisted veins) veins?

Testicular Pain in Patients with Varicocele

The most likely cause of testicular pain in a patient with a history of varicose veins (varicocele) is the varicocele itself, which causes pain through multiple mechanisms including venous congestion, increased scrotal temperature, hypoxia, and reflux of toxic metabolites—affecting 2-10% of men with varicocele. 1

Understanding the Pathophysiology

Varicocele represents pathologically enlarged, tortuous veins of the pampiniform plexus in the scrotum, present in approximately 15% of the normal male population. 2 The pain mechanism is multifactorial:

• Venous compression: Dilated venous complexes compress surrounding neural fibers 1
• Thermal injury: Elevated testicular temperature from impaired heat exchange disrupts normal testicular function 1, 3
• Metabolic toxicity: Reflux of adrenal or renal toxic metabolites causes testicular dysfunction 2, 1
• Ischemic changes: Increased venous pressure, hypoxia, and oxidative stress damage testicular tissue 2, 1

Clinical Presentation Patterns

The pain associated with varicocele typically manifests as:

• Dull, aching, or throbbing pain in the testicle, scrotum, or groin (most common presentation) 1
• Pain worsening with standing or during erection 4
• Rarely presents as acute, sharp, or stabbing pain 1
• Pain out of proportion to clinical findings suggests thrombosed varicocele (rare but important differential) 5

Critical Differential Diagnoses to Exclude

While varicocele is the likely culprit, you must systematically exclude surgical emergencies:

Testicular Torsion (Surgical Emergency)

• Abrupt onset of severe scrotal pain with decreased or absent blood flow on Doppler ultrasound 6
• Must be treated within 6-8 hours to prevent testicular loss 6
• More common in adolescents but can occur in adults 6

Epididymitis/Epididymo-orchitis

• Gradual onset of pain with enlarged epididymis showing increased blood flow on Doppler 6
• Most common cause of testicular pain in adults overall 6
• May have abnormal urinalysis (though normal urinalysis doesn't exclude it) 6

Thrombosed Varicocele (Rare but Important)

• Excruciating pain out of proportion to examination findings 5
• Can occur spontaneously or post-operatively 5
• May require urgent varicocelectomy if conservative management fails 5

Diagnostic Approach Algorithm

Step 1: Determine urgency based on pain onset

• Sudden, severe onset → Consider testicular torsion; obtain immediate Duplex Doppler ultrasound and urological consultation 6
• Gradual or chronic onset → Proceed with systematic evaluation 6

Step 2: Physical examination findings

• Palpable "bag of worms" thickening in scrotum confirms varicocele 4, 1
• Perform Valsalva maneuver to assess venous engorgement 4
• Check for testicular size asymmetry (varicocele can cause testicular hypotrophy) 3

Step 3: Imaging confirmation

• Duplex Doppler ultrasound is the imaging method of choice 4
• Assess vessel width, number of vessels in pampiniform plexus, and regurgitation during Valsalva 4
• Color Doppler shows increased blood flow in varicocele (versus decreased/absent flow in torsion) 6
• Look for the "whirlpool sign" if torsion is suspected 6

Step 4: Age-specific considerations

• Sudden onset varicocele in elderly men requires abdominal ultrasound to exclude renal tumor 4
• Adolescents with varicocele should be monitored for testicular growth asymmetry 3

Management Strategy

Conservative Management (First-Line)

Management begins with non-surgical approaches and observation period: 1

• Scrotal support
• Analgesics
• Activity modification (avoid prolonged standing)
• Observation period of several months

Surgical Intervention Indications

Varicocelectomy should be considered when: 1, 3

• Conservative management fails after adequate trial
• Clinically palpable varicocele with persistent pain
• Testicular hypotrophy or size asymmetry 3
• Bilateral varicocele 3
• Abnormal semen parameters on serial evaluation 3

Expected outcomes: Microsurgical varicocelectomy resolves testicular pain in approximately 80% of carefully selected candidates with clinically palpable varicocele. 1

Common Pitfalls and Caveats

Critical warning signs requiring urgent evaluation:

• Any sudden onset severe pain must be treated as potential torsion until proven otherwise 6
• Pain out of proportion to examination findings suggests thrombosed varicocele 5
• New varicocele in older men (>40 years) mandates evaluation for renal pathology 4

Predictors of surgical success include: 1

• Grade of varicocele (higher grades respond better)
• Nature and duration of pain
• Prior conservative management trial
• Body mass index
• Type of surgical technique used (microsurgical preferred)

Post-surgical complications to monitor: 7

• Recurrent varicocele
• Hydrocele development
• Neuralgia
• Referred pain
• Ureteral lesions (rare)

The key is recognizing that while varicocele is the most common cause of testicular pain in this population, you must systematically exclude testicular torsion through clinical assessment and appropriate imaging before attributing symptoms solely to the varicocele. 6, 1