Which description is most characteristic of a varicocele?

• A. A bag-of-worms feel superior to the testicle that worsens with standing or Valsalva and improves when supine
• B. A tender, firm lump in the scrotum that increases with activity
• C. A fixed, nonpulsatile scrotal lump that transilluminates
• D. A scrotal swelling that is pulsatile

Answer: (A)

Varicocele is a dilation of the pampiniform venous plexus in the scrotum. The hallmark is a soft, tortuous “bag-of-worms” mass that enlarges with standing or with Valsalva maneuver and collapses when the patient lies down. This follows the effect of gravity and increased intra-abdominal pressure on venous return, with recumbency improving drainage. The condition is usually left-sided because the left testicular vein drains into the left renal vein at a right angle, making it more prone to venous obstruction, though it can be bilateral. The mass is typically non-tender and does not transilluminate, helping distinguish it from a hydrocele, which does transilluminate. It’s not a fixed, solid, pulsatile lump, which helps separate it from other scrotal pathologies.