A 6-month-old boy is brought to the physician because of a right-sided scrotal swelling for the past 2 months. The swelling is intermittent and appears usually after the patient has been taken outdoors in a baby carrier, and disappears the next morning. The patient was born at term without complications and has been healthy. Examination shows a 3-cm, soft, nontender, and fluctuant right scrotal mass that is reducible and does not extend into the inguinal area. A light held behind the scrotum shines through. There are no bowel sounds in the mass. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

Ligation of the patent processus vaginalis

A 38-year-old woman presents to her primary care physician concerned about her inability to get pregnant for the past year. She has regular menstrual cycles and has unprotected intercourse with her husband daily. She is an immigrant from Australia and her past medical history is not known. She is currently taking folic acid and multivitamins. The patient's husband has had a sperm count that was determined to be within the normal range twice. She is very concerned about her lack of pregnancy and that she is too old. Which of the following is the most appropriate next step in management for this patient?

Assess ovulation with an ovulation calendar

Advise against pregnancy given the patient's age

Continue regular intercourse for 1 year

A 32-year-old man and his wife are sent to a fertility specialist after trying to conceive for several years without success. They have had unprotected sex several times a week. He has no history of a serious illness and does not take any medications. There are no concerns about his libido or erections. His female partner is not on contraceptive medication and has a child from a previous marriage. At the clinic, his vitals are normal. Examination of the scrotum on the right side is normal, but on the left side there are many deep and superficial ducts or vessels that feels like a bag of worms on palpation. The lesion is more apparent when the patient bears down. Semen analysis shows a low sperm count with poor motility and an increased percentage of abnormal sperms. Which of the following is the most appropriate next step in management?

Ligation of processus vaginalis

A 22-year-old man is brought to the emergency department because of progressive left-sided scrotal pain for 4 hours. He describes the pain as throbbing in nature and 6 out of 10 in intensity. He has vomited once on the way to the hospital. He has had pain during urination for the past 4 days. He has been sexually active with 2 female partners over the past year and uses condoms inconsistently. His father was diagnosed with testicular cancer at the age of 51 years. He appears anxious. His temperature is 36.9°C (98.42°F), pulse is 94/min, and blood pressure is 124/78 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. Examination shows a tender, swollen left testicle and an erythematous left hemiscrotum. Urine dipstick shows leukocyte esterase; urinalysis shows WBCs. Which of the following is the most appropriate next step in management?

CT scan of the abdomen and pelvis

Measurement of serum mumps IgG titer

Measurement of serum α-fetoprotein level

Male infertility surgical procedures for USMLE Step 2 CK: High-Yield Surgery Lessons

Anatomy - The Male Plumbing

Error generating content for this concept group: Failed to process successful response

🔬 Why We Operate

The primary goals are to correct reversible causes of male infertility or to retrieve sperm for Assisted Reproductive Technology (ART). Surgery addresses anatomical blockages, physiological dysfunction, or testicular failure.

Correct Anatomical Obstruction:
- Bypass or repair blockages in the reproductive tract (e.g., vas deferens, epididymis).
- Commonly for vasectomy reversal or congenital/acquired obstruction.
Improve Semen Parameters:
- Varicocelectomy: Ligation of dilated scrotal veins (varicocele) to improve testicular function and sperm quality.
Sperm Retrieval:
- For azoospermia when reconstruction is not feasible or desired.
- Essential for IVF with ICSI.

⭐ A clinically palpable varicocele, abnormal semen analysis, and documented couple infertility is the strongest indication for varicocelectomy-the most common surgically correctable cause of male infertility.

Healthy vs. Varicocele Testicle Anatomy

🛠️ Management - The Surgical Toolkit

Surgical intervention aims to correct anatomical abnormalities, reverse obstructions, or retrieve sperm for assisted reproductive technology (ART).

Varicocelectomy: Ligation of dilated pampiniform plexus veins.
- Indication: Clinically palpable varicocele + abnormal semen analysis + documented infertility.
- Goal: Improve testicular temperature regulation and semen parameters.
Vasectomy Reversal: Re-anastomosis to restore ductal patency.
- Vasovasostomy (VV): Connects vas deferens ends.
- Vasoepididymostomy (VE): Connects vas deferens to epididymis if epididymal blockage is found.

⭐ Microsurgical varicocelectomy is the gold standard, offering the highest pregnancy rates and lowest rates of recurrence and complications (e.g., hydrocele, testicular artery injury).

Sperm Retrieval for ART (IVF/ICSI):

Technique	Abbreviation	Primary Indication	Key Feature
Microsurgical TESE	microTESE	NOA	Highest yield; preserves testicular tissue
Microsurgical Epididymal	MESA	OA	Highest quality sperm; open procedure
Percutaneous Epididymal	PESA	OA	Less invasive; "blind" needle aspiration

⚠️ Complications - Potential Pitfalls

Varicocelectomy:
- Hydrocele: Most common; due to lymphatic vessel ligation.
- Testicular Artery Injury: Most feared; leads to testicular atrophy.
- Persistence/Recurrence: Occurs in up to 15% of cases.
Vasovasostomy / Vasoepididymostomy (V-V / V-E):
- Anastomotic Stricture: Scarring leads to re-obstruction.
- Sperm Granuloma: Inflammatory reaction to extravasated sperm.
- Hematoma, infection, chronic scrotal pain.
TESE / MESA:
- Testicular Hematoma/Fibrosis: Can impair future function.
- Devascularization & Hypogonadism (↓ testosterone).

⭐ Post-varicocelectomy hydrocele is the most frequent complication, but iatrogenic testicular artery injury is the most devastating, causing irreversible testicular atrophy.

⚡ Biggest Takeaways

Varicocelectomy is the most common surgical correction for male infertility, improving semen parameters by ligating dilated pampiniform plexus veins.

Vasectomy reversal success is inversely related to the time since vasectomy; vasovasostomy is the most common technique.

Sperm retrieval (TESE, MESA) is essential for azoospermia and requires Intracytoplasmic Sperm Injection (ICSI) for fertilization.

TURED (Transurethral Resection of Ejaculatory Duct) treats obstructive azoospermia caused by midline prostatic cysts or scarring.

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play