0022-534 7 /90/1441-0138$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 144, July
Printed in U.S.A.
EFFORT-INDUCED SPONTANEOUS THROMBOSIS OF THE LEFT SPERMATIC VEIN PRESENTING CLINICALLY AS A LEFT INGUINAL HERNIA JEFFREY SCOTT ISENBERG, GOKHAN OZUNER, MELVIN H. WORTH
AND
GEORGE FERZLI
From the Department of Surgery, Staten Island Hospital, Staten Island, New York ABSTRACT
A unique case of exercise-induced spontaneous thrombosis of the spermatic vein that presented as an incarcerated left inguinal hernia is described. This entity may be clinically indistinguishable from many surgical conditions. Venography of the spermatic vein can be diagnostic but it should not delay surgical intervention. (J. Ural., 144: 138, 1990) Isolated thrombosis of the spermatic vein is a rare clinical entity, with only a few cases reported in the literature. 1- 3 We describe a case of exercise-induced thrombosis of the spermatic vein that presented clinically as an inguinal hernia. CASE REPORT
A 19-year-old man presented to the emergency room complaining of pain in the left groin area after several hours of vigorous aerobic excercise. Specifically, the patient related performing 1 hour of aerobic exercises, and 1 hour of rowing and sit-ups. The patient had no other medical or surgical history. At physical examination a 2 cm. painful irreducible mass was palpated in the left inguinal canal at the level of the external inguinal ring. The left testis was of normal size and nontender to palpation, as was the epididymis. No evidence of varicocele was noted on physical examination. Preoperative diagnosis was incarcerated left inguinal hernia. Exploration of the left inguinal canal revealed thrombosis of the left spermatic vein at the level of the internal inguinal ligament (see figure). The other vessels within the spermatic cord were grossly normal. The thrombosed vein was resected and convalescence was uneventful. DISCUSSION
Several theories have been proposed to account for spontaneous thrombosis of the spermatic vein, most of which are founded upon anatomical considerations. The veins of the spermatic cord arise from the testis and epididymis, are joined by others from the globus major and ascend in the spermatic cord as the pampiniform plexus. These veins are remarkable for their number, size and tendency to become varicose. The plexus merges into a distinct spermatic vein in the inguinal canal, with the vessel on the right side joining the inferior vena cava and that on the left side entering the renal vein. Therefore, the left spermatic vein follows a much longer course and is subject to more frequent varicocele formation (98% of the cases). 4 The left sigmoid colon also may impinge on the vein along its course, with postulated impedance to venous return and subsequent venous thrombosis. The precise etiology of spontaneous thrombosis of the spermatic vein is unknown. A syndrome of painful engorgement of the pampiniform plexus after prolonged sexual activity has been described 5 but this was not a factor in our patient. There also have been reports of spermatic vein thrombosis in patients with thromboangitis obliterans and renal tumors. 6 When one considers the repeated abdominal exercises (sit-ups) performed by the patient one may hypothesize a temporary state of decreased venous return in the spermatic vein produced by the shutter mechanism of the contracting internal oblique muscle, leading to thrombosis. The temporal sequence of events lends support to this hypothesis. Accepted for publication February 1, 1990. 138
Sectioned specimen shows thrombosis of spermatic vein
Clinically, spermatic vein thrombosis is indistinguishable from many other clinical conditions that present as masses in the groin, including varicoceles, hydroceles, spermatoceles, inguinal hernia, spermatic cord torsion, spermatic cord hematoma, vasitis, folliculitis, primary and metastatic tumors, and thromboangitis obliterans. 7' 8 Unfortunately, there are few diagnostic aids beyond history and physical examination to assist in the differentiation of the surgical from nonsurgical entities. In our patient spermatic vein venography would have been diagnostic. However, due to the rarity of this condition it was not entertained in the preoperative diagnosis and venography was not obtained. The use of venography in this instance would have prevented an operation, since spermatic vein thrombosis can be managed conservatively with bed rest, heat and relief of pain. However, such an approach may place patients with an incarcerated inguinal hernia at risk by delaying operative intervention and, therefore, it cannot be recommended. REFERENCES
1. McGavin, D.: Thrombosis of the pampiniform plexus. Lancet, 2: 368, 1935. 2. Anseline, P.: A case of spontaneous thrombosis of the pampiniform plexus of the testis. Aust. New Zeal. J. Surg., 47: 801, 1977. 3. Vincent, M. P. and Bokinsky, G.: Spontaneous thrombosis of the pampiniform plexus. Urology, 17: 175, 1981. 4. Rothman, D.: Thrombosis of the pampiniform plexus. J. Med. Soc. New Jersey, 78: 681, 1981. 5. Nation, E. F.: Swellings of the spermatic cord, epididymis and testicular tunics and appendages. Postgrad. Med., 33: 434, 1963. 6. Bissada, N. K. and Redman, J. F.: Unusual masses in the spermatic cord: report of six cases and review of the literature. South. Med. J., 69: 1410, 1976. 7. Boyce, W. H. and Politano, V. A.: Infections and diseases of the scrotum and its contents. In: Urology. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 16,pp. 616-624, 1970. 8. Gibson, T. E.: Tumors of the seminal vesicles, spermatic cord, epididymis, and testicular tunics. In: Urology. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 2, chapt. 31, pp. 1235-1245, 1970.
Vol. 144, July
Printed in U.S.A.
EFFORT-INDUCED SPONTANEOUS THROMBOSIS OF THE LEFT SPERMATIC VEIN PRESENTING CLINICALLY AS A LEFT INGUINAL HERNIA JEFFREY SCOTT ISENBERG, GOKHAN OZUNER, MELVIN H. WORTH
AND
GEORGE FERZLI
From the Department of Surgery, Staten Island Hospital, Staten Island, New York ABSTRACT
A unique case of exercise-induced spontaneous thrombosis of the spermatic vein that presented as an incarcerated left inguinal hernia is described. This entity may be clinically indistinguishable from many surgical conditions. Venography of the spermatic vein can be diagnostic but it should not delay surgical intervention. (J. Ural., 144: 138, 1990) Isolated thrombosis of the spermatic vein is a rare clinical entity, with only a few cases reported in the literature. 1- 3 We describe a case of exercise-induced thrombosis of the spermatic vein that presented clinically as an inguinal hernia. CASE REPORT
A 19-year-old man presented to the emergency room complaining of pain in the left groin area after several hours of vigorous aerobic excercise. Specifically, the patient related performing 1 hour of aerobic exercises, and 1 hour of rowing and sit-ups. The patient had no other medical or surgical history. At physical examination a 2 cm. painful irreducible mass was palpated in the left inguinal canal at the level of the external inguinal ring. The left testis was of normal size and nontender to palpation, as was the epididymis. No evidence of varicocele was noted on physical examination. Preoperative diagnosis was incarcerated left inguinal hernia. Exploration of the left inguinal canal revealed thrombosis of the left spermatic vein at the level of the internal inguinal ligament (see figure). The other vessels within the spermatic cord were grossly normal. The thrombosed vein was resected and convalescence was uneventful. DISCUSSION
Several theories have been proposed to account for spontaneous thrombosis of the spermatic vein, most of which are founded upon anatomical considerations. The veins of the spermatic cord arise from the testis and epididymis, are joined by others from the globus major and ascend in the spermatic cord as the pampiniform plexus. These veins are remarkable for their number, size and tendency to become varicose. The plexus merges into a distinct spermatic vein in the inguinal canal, with the vessel on the right side joining the inferior vena cava and that on the left side entering the renal vein. Therefore, the left spermatic vein follows a much longer course and is subject to more frequent varicocele formation (98% of the cases). 4 The left sigmoid colon also may impinge on the vein along its course, with postulated impedance to venous return and subsequent venous thrombosis. The precise etiology of spontaneous thrombosis of the spermatic vein is unknown. A syndrome of painful engorgement of the pampiniform plexus after prolonged sexual activity has been described 5 but this was not a factor in our patient. There also have been reports of spermatic vein thrombosis in patients with thromboangitis obliterans and renal tumors. 6 When one considers the repeated abdominal exercises (sit-ups) performed by the patient one may hypothesize a temporary state of decreased venous return in the spermatic vein produced by the shutter mechanism of the contracting internal oblique muscle, leading to thrombosis. The temporal sequence of events lends support to this hypothesis. Accepted for publication February 1, 1990. 138
Sectioned specimen shows thrombosis of spermatic vein
Clinically, spermatic vein thrombosis is indistinguishable from many other clinical conditions that present as masses in the groin, including varicoceles, hydroceles, spermatoceles, inguinal hernia, spermatic cord torsion, spermatic cord hematoma, vasitis, folliculitis, primary and metastatic tumors, and thromboangitis obliterans. 7' 8 Unfortunately, there are few diagnostic aids beyond history and physical examination to assist in the differentiation of the surgical from nonsurgical entities. In our patient spermatic vein venography would have been diagnostic. However, due to the rarity of this condition it was not entertained in the preoperative diagnosis and venography was not obtained. The use of venography in this instance would have prevented an operation, since spermatic vein thrombosis can be managed conservatively with bed rest, heat and relief of pain. However, such an approach may place patients with an incarcerated inguinal hernia at risk by delaying operative intervention and, therefore, it cannot be recommended. REFERENCES
1. McGavin, D.: Thrombosis of the pampiniform plexus. Lancet, 2: 368, 1935. 2. Anseline, P.: A case of spontaneous thrombosis of the pampiniform plexus of the testis. Aust. New Zeal. J. Surg., 47: 801, 1977. 3. Vincent, M. P. and Bokinsky, G.: Spontaneous thrombosis of the pampiniform plexus. Urology, 17: 175, 1981. 4. Rothman, D.: Thrombosis of the pampiniform plexus. J. Med. Soc. New Jersey, 78: 681, 1981. 5. Nation, E. F.: Swellings of the spermatic cord, epididymis and testicular tunics and appendages. Postgrad. Med., 33: 434, 1963. 6. Bissada, N. K. and Redman, J. F.: Unusual masses in the spermatic cord: report of six cases and review of the literature. South. Med. J., 69: 1410, 1976. 7. Boyce, W. H. and Politano, V. A.: Infections and diseases of the scrotum and its contents. In: Urology. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 16,pp. 616-624, 1970. 8. Gibson, T. E.: Tumors of the seminal vesicles, spermatic cord, epididymis, and testicular tunics. In: Urology. Edited by M. F. Campbell and J. H. Harrison. Philadelphia: W. B. Saunders Co., vol. 2, chapt. 31, pp. 1235-1245, 1970.
