Seasonal Case Recap: Torsion in the Middle of Summer – or Just a Varicocele? Case No: ABD.3.4.003

A case that made me think a lot, even without any images — and taught me even more.

During my night shifts this week, three young patients presented with an identical clinical scenario.

Interestingly, all three patients  complained of left-sided scrotal pain for a few days.

On physical exam: no redness, no warmth. But tenderness on elevation

Typically, Prehn's sign is characterized by the relief of pain with scrotal elevation, which usually suggests epididymitis. However, in our cases, the pain actually exacerbated upon elevation. While this ruled out acute epididymitis, it significantly increased our clinical suspicion for testicular torsion

Ultrasound Findings:

Testes were normal in volume and echotexture.

Epididymis was unremarkable.

Symmetric and preserved vascular flow in both testes — no increase or reduction. Doppler waveforms demonstrate a monophasic, low-resistance pattern.

But what stood out was:

Marked soft tissue edema in the left scrotal wall compared to the right.

And Grade 3 varicocele on the left side.

Interestingly, both patients had nearly identical sonographic findings.

> Torsion?

Past epididymo-orchitis?

Venous stasis causing reactive changes?

☀️ Heat, Summer & Scrotal Veins

It’s been very hot and humid lately — with lots of sweating and long hours standing.

In three  patients:

Normal testes and epididymis + diffuse left-

sided scrotal wall edema + venous congestion.

🔍 What Did Radiology Say?

Not torsion.

Not epididymo-orchitis — at least not in its active phase.

But combining the unilateral edema + prominent varicocele + clinical story →

Suggested transient venous stasis and reactive edema triggered by heat-induced varicocele exacerbation.

🧠 Clinical-Radiological Correlation:

✅ Left-sided diffuse scrotal wall edema + short-lived pain + no current erythema or warmth:

📌 Three scenarios come to mind:

1. Subacute or past epididymo-orchitis (resolved or untreated):

Initially may cause pain, erythema, and warmth.

Symptoms improve over a few days, but the scrotal wall edema can persist.

If Doppler still showed hyperemia, this would support it — but in our cases, it was normal.

2. Grade 3 varicocele + venous stasis → passive edema:

May cause pain (especially after standing or exercising).

Can lead to mild inflammatory reaction and scrotal wall edema.

Typically chronic but may flare up acutely.

3. Lymphatic drainage disorder / impaired venous return (with varicocele contribution):

Again, unilateral edema possible.

Pain may occur, but erythema or warmth may not be present.

In these cases, the overlapping clinical and radiologic features pointed us toward

heat-aggravated varicocele with reactive edema due to transient venous stasis.

🔄 What to Do / What to Watch For:

– If the patient experiences pain or erythema again → Repeat Doppler to rule out epididymo-orchitis.

– Follow-up scrotal wall thickness → If regressing, infection becomes more likely.

– As long as varicocele-induced drainage issues persist, such edema episodes may recur.

– If the patient is young and has a history of infertility, surgical or embolization options for Grade 3 varicocele should be considered.