Answer The Question: 23-Year-Old Healthy Man Has Been Unable

Answer The Questiona 23 Year Old Healthy Man Has Been Unable To Father

A 23-year-old healthy man has experienced an inability to father a child. His wife's reproductive function is normal, and physical examination reveals that both testes are palpable in the scrotum, of normal size, with no palpable masses. Notably, the spermatic cord on the left side feels like a “bag of worms.” Laboratory studies indicate oligospermia, a condition characterized by a low sperm count. The question asks which condition is most likely to explain these findings.

Understanding the clinical features is essential for diagnosing the most probable cause of infertility in this patient. The physical examination findings, particularly the "bag of worms" sensation in the spermatic cord, are characteristic of varicocele, a common condition associated with male infertility. The presence of oligospermia further supports this diagnosis. This essay explores the clinical features, pathology, and implications of the conditions listed, emphasizing why varicocele is the most probable diagnosis in this case.

Clinical Background and Diagnostic Features

Varicocele

Varicocele is an abnormal dilation of the pampiniform venous plexus in the scrotum, resembling a “bag of worms,” which aligns exactly with this patient's physical exam findings (Kumar et al., 2019). It is present in approximately 15% of all males and up to 40% of men presenting with infertility (Kim & Jacobs, 2020). Typically, varicoceles are more prominent on the left side due to the anatomy of the left testicular vein, which drains into the left renal vein at a right angle, predisposing it to higher venous pressure and dilation (Kumar et al., 2019). This anatomical feature explains why the patient's left spermatic cord felt like a "bag of worms."

Clinically, varicoceles are often asymptomatic but can contribute to impaired spermatogenesis. They are diagnosed via physical examination—anechoic, tortuous veins palpable during the Valsalva maneuver—and confirmed with imaging, such as scrotal Doppler ultrasound, which reveals venous dilation and reflux.

Mechanism of Oligospermia in Varicocele

The pathophysiology involves increased scrotal temperature, hypoxia, and oxidative stress, which impair spermatogenesis (Cacciatore & Muzii, 2021). The increased venous pressure hampers the efficient cooling of the testes, leading to hyperthermia—a known factor in spermatogenic dysfunction. Oxidative stress results from reactive oxygen species damaging sperm DNA and membranes, decreasing sperm quality and count (Cacciatore & Muzii, 2021). These mechanisms elucidate the connection between varicocele and oligospermia.

Other Conditions Explained

- Hydrocele: Accumulation of fluid in the tunica vaginalis causes scrotal swelling but does not produce a "bag of worms" sensation and is not associated with oligospermia (Brown et al., 2018).

- Testicular Torsion: An acute emergency, characterized by pain and swelling due to twisting of the spermatic cord, which impairs blood flow. It is not associated with infertility or a "bag of worms" feel (Smith & Cohen, 2019).

- Spermatocele: A cystic dilatation of the epididymal efferent duct, presenting as a painless, cystic mass separate from the testis, without vascular symptoms or "bag of worms" features (Brown et al., 2018).

- Seminoma: A germ cell tumor presenting as a firm, painless testicular mass, often with no associated vascular abnormalities or varicocele. It typically presents with a distinct mass rather than varicocele symptoms (Smith & Cohen, 2019).

Given these considerations, varicocele best explains the physical findings and the laboratory evidence of oligospermia.

Conclusion

The most likely diagnosis in this 23-year-old man with infertility, palpable testes, and a "bag of worms" sensation in the spermatic cord, coupled with oligospermia, is D. Varicocele. Its characteristic features—local venous dilation of the pampiniform plexus, especially on the left side—correlate with the clinical and laboratory findings. Varicoceles are a common, correctable cause of male infertility, significant because addressing them surgically can improve spermatogenesis in many cases (Kumar et al., 2019). Therefore, appropriate diagnosis and treatment can mitigate the effects of varicocele and potentially restore fertility.

References

• Cacciatore, C., & Muzii, L. (2021). The pathophysiology of varicocele-related infertility. Reproductive Biology and Endocrinology, 19(1), 123. https://doi.org/10.1186/s12958-021-00796-0
• Kim, H., & Jacobs, L. (2020). Varicocele and male infertility: An overview. Urologic Clinics of North America, 47(4), 479-493. https://doi.org/10.1016/j.ucl.2020.07.003
• Kumar, S., Gupta, N., & Goel, A. (2019). Clinical and diagnostic approach to varicocele. Indian Journal of Urology, 35(4), 265-271. https://doi.org/10.4103/iju.IJU_376_18
• Brown, S., Weiss, R., & Fisher, OR. (2018). Differential diagnosis of scrotal masses. Urologic Pathology, 6(3), 189-198. https://doi.org/10.1016/j.uropath.2018.01.002
• Smith, P., & Cohen, R. (2019). Clinical presentation and management of testicular torsion. Urology Journal, 16(4), 518-523. https://doi.org/10.22037/uj.v16i4.6087