A 14-year-old boy presents with a 3-month history of a left-sided scrotal swelling that is more prominent on standing and reduces when lying down. On examination, the left scrotum contains a dilated, tortuous mass described as a 'bag of worms' above the testis. The left testis is smaller than the right. He is asymptomatic otherwise. What is the most appropriate next step in management?

• A Surgical repair with testicular volume monitoring given left testicular atrophy ✓
• B Scrotal ultrasound with Doppler
• C Observation with annual follow-up if testicular volumes are symmetric
• D Immediate surgical ligation of the left testicular vein

Explanation

Adolescent varicocele is common on the left side and presents as a 'bag of worms' that decompresses supine. Indications for surgical repair include a >2 mL difference in testicular volume (testicular atrophy on the affected side), pain, or abnormal semen parameters. Since this patient has a smaller left testis, surgical repair with monitoring of catch-up growth is indicated. Observation is reserved for symmetric testicular volumes. Ultrasound confirms diagnosis but is not the next step when clinical diagnosis is clear.

Reference: Campbell-Walsh Urology, 12th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.