Summary: Patient A: A 35-year-old Hispanic man presented to the
emergency department with acute onset of left testicular pain. He had no
significant past medical history. The physical exam was unremarkable.
Summary: Patient B:
A 37-year-old man presented to the emergency department with left-sided
testicular pain after trauma. Past medical history included prior
hematoma evacuation in the left scrotum. These patients were referred
for testicular ultrasounds.
Patient A: Real-time, gray-scale ultrasonography demonstrated
testes that were symmetric in size and homogenous in echotexture.Dilated
tubular hypoechoic structures were noted coursing through the left
testicle (Figure 1). One had a more oval shape (Figure 2).Color Doppler
demonstrated that these were indeed vascular lesions with a venous
waveform upon spectral analysis. Dilated tubular extratesticular vessels
were also identified in the left hemiscrotum.
Real-time, gray-scale imaging demonstrated a smaller atrophic left
testis. Incidental note was made of an intratesticular mass on the
right. Dilated tubular hypoechoic structures were noted in the left
testis (Figure 3). An increase in venous flow was noted in these vessels
during a Valsalva maneuver, as well as in the ipsilateral varicocele
Though extratesticular varicocele is a common condition, occurring in
approximately 15% of men, an intratesticular varicocele (ITV) is a rare
entity. It was first described in 1992 by Weiss et al1 and
has since been noted in about 60 case reports. Two of the largest
studies have shown a prevalence of 1.2% to 2% in symptomatic men
referred for sonography.2,3 It is, therefore, an incompletely
understood condition. We present two case reports from our institution
with some similarities and differences when compared with what is known
Sonographic findings include multiple hypoechoic,
serpiginous, and tubular intratesticular structures of various sizes
with low-levelinternal echoes. Doppler demonstrates a low-flow venous
pattern. It was first considered always to be associated with an
ipsilateral varicocele. Das et al2 showed that 44% were associated with an ipsilateral varicocele while Kessler et al.3
showed this association to be 86%. Though mostly found in the left
testis, bilateralism has been shown in 25% 3 to 39% of cases.2
Both of our cases are on the left and coexist with an extratesticular
varicocele. They are subcapsular in 60% and confined to the mediastinum
in 40%.3 Das et al2 were the first to describe a
variation in the usual tubular shape, an oval varicocele, which we also
demonstrate in patient A. The tubular-shaped lesions are less of a
diagnostic challenge. The oval lesions must be differentiated from an
intratesticular mass. The differential diagnosis includes a cyst,
abscess, hematoma, tubular ectasia, cystic neoplasm, or a
psuedoaneursym.4 Color Doppler can be helpful. Das et
al.found that 28% of the lesions required power Doppler and/or a
valsalva maneuver to make the diagnosis of ITV.2 Kessler et al found a greater need for adjunctive imaging techniques in 40% of their patients.3
Color Doppler was sufficient for the diagnosis in our patients, though
Valsalva helped. Ho et al described a patient with a 44% reduction in
testicular volume over a 2-year follow-up in a patient with an ITV and
ETV.5 Patient B demonstrates a loss in volume in the testis
with the ITV relative to the contralateral testis. However, it is
unclear whether the volume loss is related to a prior hematoma
We present two patients with the rare entity of intratesticular
varicocele. Their imaging characteristics are described and compared to
previously known cases. Awareness and description of more cases will
help further elucidate the clinical significance of this entity.
- Weiss AJ, Kellman GM, Middleton WD, Kirkemo, A. Intratesticular varicocele: Sonographic findings in two patients. AJR Am J Roentgenol. 1992;158:1061–1063.
- Das KM, Prasad K, Szmigielski W, Noorani N. Intratesticular varicocele: Evaluation using conventional and Doppler sonography. AJR Am J Roentgenol. 1999;173:1079– 1083.
- Kessler A, Meirsdorf S, Graif M, et al. Intratesticular varicocele: Grayscale and color Doppler sonographic appearance. J Ultrasound Med. 2005;24:1711–1716.
- Dogra VS, Gottlieb RH, Rubens DJ, Liao, L. Benign intratesticular cystic lesions: US features. Radiographics. 2001; 21:S273–S281.
- Ho K, Mcateer E, and Young M. Loss of testicular volume associated with intratesticular varicocele. Int J Urol. 2005;12:422–423.