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A usually painless scrotal swelling, called a varicocele, is a collection of
abnormally enlarged spermatic cord veins most commonly found on routine
examination of asymptomatic boys ages 10 to 15 years. Most varicoceles occur
on the left, representing spermatic vein incompetence caused by the left spermatic
vein draining into the renal vein at a sharp angle, whereas the right spermatic vein
drains into the inferior vena cava.
On occasion, a varicocele can present with mild pain or discomfort. The
hemiscrotum appears full but overlying skin is normal. The testis and epididymis
should be palpated to be normal. A mass of varicose veins described as “a bag of
worms” can be appreciated above the testicle, which is more prominent when
examined while standing. Doppler ultrasound demonstrates both normal flow to
the testis and the collection of tortuous veins. Most varicoceles are asymptomatic
and benign and just observed. Patients determined to have a varicocele, especially
when they present with discomfort, should be referred for urologic follow-up.
Some large varicoceles may require internal spermatic vein ligation or testicular
vein embolization and may effect testicular size and fertility. Inferior vena cava
obstruction should be considered when the patient is prepubertal or if the
varicocele is acute in onset, right sided, or remains unchanged in the supine
position.

Spermatocele
Located above and posterior to the testicle in postpubertal boys, spermatoceles
are sperm-containing cysts of the rete testes, ductuli efferentes, or epididymis.
Multiple and bilateral spermatoceles may occur. On examination a small,
nontender mass that transilluminates may be appreciated distinct from and
posterior to the testicle. These masses must be differentiated from a hydrocele or
tumor. Sonography may confirm the location and help distinguish a spermatocele
from tumor. Referral to a urologist is indicated for the excision of large
uncomfortable spermatoceles or for aspiration to differentiate a hydrocele from a
spermatocele. Otherwise, no specific treatment is needed (see Chapter 119
Genitourinary Emergencies ).

Idiopathic Scrotal Edema
Idiopathic scrotal edema is a rare entity that represents only 2% to 5% of acute
scrotal swellings in otherwise normal children. Typically, a prepubertal child
presents with the rapid onset of painless edema of the scrotal wall that may be
bilateral and may extend up onto the abdomen. The skin of the scrotum may be
erythematous. The child is usually afebrile, and urinalysis is negative. Through
the edematous scrotum, the testes can be felt to be normal in size and nontender.