Most Likely Diagnosis: Left Inguinal/Spermatic Cord Varicocele
The clinical presentation of intermittent dull-aching left testicular pain worsened by heavy lifting (Valsalva maneuver), a palpable bulge along the upper left spermatic cord, and absence of acute inflammatory signs strongly suggests a left-sided varicocele as the primary diagnosis. The history of treated chlamydial epididymitis is likely coincidental and unrelated to the current presentation.
Key Diagnostic Features Supporting Varicocele
The pain pattern is pathognomonic: dull-aching discomfort exacerbated by prolonged standing, heavy lifting, or Valsalva maneuvers, with relief when supine, is classic for varicocele 1.
The palpable bulge along the spermatic cord in the upper scrotum represents dilated pampiniform plexus veins, often described as a "bag of worms" on examination 1.
Left-sided predominance occurs in approximately 90% of varicoceles due to the left testicular vein draining into the left renal vein at a right angle (versus the right testicular vein draining directly into the IVC), combined with absent or incompetent valves 1.
Age and demographics: varicoceles are present in 15% of men and most commonly present between ages 15-30, making this 23-year-old patient典型 1.
Critical Differential Considerations
Rule Out Secondary Causes (Red Flags)
Acute onset or isolated right-sided varicocele in a patient >40 years would mandate urgent imaging to exclude retroperitoneal malignancy compressing the testicular vein 1.
Varicocele that does not decompress when supine suggests venous obstruction from an intra-abdominal mass and requires CT/MRI of the abdomen 1.
In this 23-year-old with left-sided varicocele that developed gradually, secondary causes are unlikely, but given the recurrent nature after treatment for epididymitis, consider atypical etiologies like Nutcracker Syndrome (left renal vein compression) if hematuria is present 2.
Epididymitis Recurrence (Less Likely)
The absence of scrotal swelling, fever, or dysuria makes recurrent epididymitis unlikely 3.
Epididymitis typically presents with gradual onset of pain, enlarged tender epididymis, and increased blood flow on Doppler ultrasound 3.
The pain pattern (worsened by lifting, improved with rest) is inconsistent with infectious/inflammatory etiology 3.
Diagnostic Workup Algorithm
1. Physical Examination Maneuvers
Examine patient both supine and standing – varicoceles become more prominent when standing and decompress when supine 1.
Palpate for the classic "bag of worms" texture along the spermatic cord 1.
Perform Valsalva maneuver during palpation – varicocele will enlarge with increased intra-abdominal pressure 1.
2. Scrotal Doppler Ultrasound (First-Line Imaging)
Grayscale ultrasound will show dilated veins (>2-3mm diameter) in the pampiniform plexus 3.
Color Doppler demonstrates venous reflux with Valsalva maneuver or standing position 3.
Ultrasound also excludes testicular torsion, epididymitis, and testicular masses that may present with similar symptoms 3, 4.
3. Additional Imaging if Atypical Features Present
If varicocele does not decompress supine or patient has hematuria, obtain CT angiography to evaluate for Nutcracker Syndrome (left renal vein compression between aorta and SMA) 2.
If right-sided or bilateral varicocele, obtain abdominal/pelvic CT to exclude retroperitoneal mass 1, 5.
Management Approach
Conservative Management (First-Line for Most Patients)
Reassurance is appropriate for asymptomatic or minimally symptomatic varicoceles in young men without fertility concerns 1.
Supportive measures include scrotal support (athletic supporter), NSAIDs for pain, and avoiding prolonged standing or heavy lifting 1.
No routine referral to urology is needed for typical left-sided varicocele in a young man without fertility issues or severe pain 1.
Indications for Urology Referral
Significant bothersome pain despite conservative management warrants referral for consideration of varicocelectomy 1.
Fertility concerns – varicoceles are present in up to 40% of subfertile men, though most achieve natural conception without intervention. Refer to urologist with fertility expertise for counseling on varicocelectomy versus assisted reproduction 1.
Atypical features requiring further investigation (right-sided, non-decompressing, associated mass) 1.
Testicular atrophy on examination suggests chronic venous congestion affecting testicular function 1.
Common Pitfalls to Avoid
Do not assume recurrent epididymitis without objective findings (fever, pyuria, enlarged tender epididymis on ultrasound) – this leads to unnecessary antibiotic courses 3.
Do not miss testicular torsion in any patient with acute testicular pain – though this patient's 2-month history and pain pattern make torsion unlikely, any acute worsening requires urgent evaluation 3.
Do not overlook red flags for secondary varicocele – acute onset, right-sided, age >40, non-decompressing, or associated hematuria all mandate cross-sectional imaging 1, 2.
Do not routinely image or refer young men with typical left varicoceles – clinical diagnosis is sufficient and most require only reassurance 1.