What are the distinguishing clinical signs and symptoms of varicocele versus epididymitis in adolescent and young adult males?

Distinguishing Varicocele from Epididymitis

Key Clinical Presentation Differences

Varicocele and epididymitis present with fundamentally different clinical pictures: varicocele is typically a chronic, often asymptomatic condition characterized by dilated pampiniform plexus veins that feel like a "bag of worms," while epididymitis presents acutely with painful, tender scrotal swelling and systemic signs of infection. 1

Varicocele Clinical Features

Presentation and Physical Examination:

• Present in approximately 15% of normal males and 25% of men with abnormal semen analysis 2
• Typically asymptomatic or presents with dull, aching scrotal discomfort that worsens with prolonged standing 3, 4
• Classic "bag of worms" feeling on palpation of the spermatic cord 3
• More prominent when standing; decreases or disappears when supine 3
• Left-sided predominance (85-90% of cases) due to anatomical differences in venous drainage 3
• No fever, no acute pain, no urinary symptoms 4

Ultrasound Findings:

• Dilated pampiniform plexus veins >3 mm in diameter 5
• Increased venous flow with Valsalva maneuver on color Doppler 3
• Normal testicular blood flow and echogenicity 3

Epididymitis Clinical Features

Presentation and Physical Examination:

• Gradual onset of unilateral scrotal pain and swelling over hours to days 1, 6
• Tender, enlarged epididymis on palpation 1, 4
• Positive Prehn sign (pain relief with testicular elevation) in many cases 1
• Fever and systemic symptoms often present 7, 4
• Scrotal wall erythema and warmth 1, 7
• May have urethral discharge or dysuria suggesting sexually transmitted infection 7, 4
• Pyuria on urinalysis (though normal urinalysis does not exclude diagnosis) 1

Ultrasound Findings:

• Enlarged epididymis with increased blood flow on color Doppler 1, 7
• Scrotal wall thickening and possible hydrocele 1
• Normal or increased testicular blood flow (hyperemia) 1
• Up to 20% develop concomitant orchitis 1

Critical Diagnostic Algorithm

Step 1: Assess Onset and Pain Pattern

• Acute onset (<24-48 hours) with severe pain → Consider epididymitis or testicular torsion 1, 6
• Chronic or gradual onset with dull ache → Consider varicocele 3, 4

Step 2: Perform Focused Physical Examination

• Palpate for "bag of worms" texture that increases with standing/Valsalva → Varicocele 3
• Assess for focal epididymal tenderness and swelling → Epididymitis 1, 4
• Check for fever and scrotal wall erythema → Suggests infection (epididymitis) 7, 4

Step 3: Obtain Urinalysis

• Pyuria or bacteriuria supports epididymitis diagnosis 1, 4
• Normal urinalysis does not exclude either condition but makes infection less likely 1

Step 4: Doppler Ultrasound When Diagnosis Unclear

• Dilated veins >3 mm with reflux on Valsalva → Varicocele 3, 5
• Enlarged epididymis with hyperemia → Epididymitis 1, 7

Important Clinical Pitfalls

Coexistence of Both Conditions:

• Left-sided varicocele is significantly more common in patients with epididymitis (66.7% vs 22.3% in controls), likely due to chronic venous stasis predisposing to infection 5
• The presence of varicocele does not exclude acute epididymitis 5, 8
• Always assess for acute infectious symptoms even in patients with known varicocele 5

Testicular Torsion Must Be Excluded:

• Any acute scrotal pain requires urgent evaluation to exclude torsion, which presents with sudden severe pain, absent cremasteric reflex, and requires surgery within 6-8 hours 1, 7
• Epididymitis has gradual onset; torsion has abrupt onset 1
• When clinical suspicion for torsion is high, proceed directly to surgical exploration rather than delaying for imaging 1

Age-Related Considerations:

• In adolescents and young adults (<25 years), consider sexually transmitted causes of epididymitis (Chlamydia trachomatis, Neisseria gonorrhoeae) 7, 4
• In men >35 years, enteric organisms are more common causes of epididymitis 1, 4
• Varicocele typically presents in adolescence or young adulthood 2, 3

Management Implications

Varicocele:

• Most require no treatment unless associated with infertility, testicular atrophy, or significant pain 2, 4
• Surgical repair indicated for documented infertility with abnormal semen parameters 2
• Observation appropriate for asymptomatic cases 4, 6

Epididymitis:

• Requires antibiotic therapy: ceftriaxone 250 mg IM plus doxycycline 100 mg PO twice daily for 10 days for sexually transmitted causes 7
• Adjunctive therapy includes bed rest, scrotal elevation, and analgesics 7, 4
• Failure to improve within 3 days mandates reevaluation for complications 7