Ann R Coll Surg Engl 2010; 92:1 Acute thrombosis of the pampiniform plexus is an uncommon clinical problem, 1 which causes a diagnostic conundrum in men presenting urgently to medical personnel. We present an unusual case of a young man who presented with metachronous thromboses of his pampiniform plexi and review the literature to explore potential aetiologies and therapeutic strategies.
Case historyA 21-year-old, male, junior soldier presented as an emergency to our hospital complaining of an acute, painful, leftsided, testicular swelling. The pain had started a few hours prior to his attendance at the hospital, whilst he was involved with routine physical training at the army headquarters. This involved high intensity exercise in routine combat attire. His past medical and surgical history were unremarkable. On examination, the patient was in significant discomfort with a tender, swollen left hemiscrotum. The left testis appeared to lie horizontally within the scrotum and in a high position. There was an absent cremasteric reflex and the cord structures were indistinguishable. The remainder of the physical examination was normal with no obvious inguinal hernia or abdominal problem. A diagnosis of acute, left testicular torsion was established and the patient admitted for emergency surgical exploration. At surgery, the left pampiniform plexus was thrombosed distal to the superficial, inguinal ring. The left testis and epididymis were normal. The diagnosis was confirmed with a biopsy and the wound was closed in layers. Subsequent haematological investigations for a hypercoagulable state and a computed tomography (CT) scan of his abdomen/pelvis were normal. The patient recovered without any complications and was discharged 2 days postoperatively. However, 1 month later, he presented with a painful right testis. Once again, he had been involved in high intensity, physical training; on this occasion, a scrotal ultrasound confirmed thrombosis of the contralateral pampiniform plexus. The patient settled promptly with bed rest and simple analgesia.
DiscussionSpontaneous thrombosis of the pampiniform plexus is a rare clinical problem, with only 15 cases reported in the literature with one case of bilateral involvement. Hashimoto and Vibeto 1 noted that there was a preponderance of leftsided, clinical presentations with presumed, shared anatomical factors which can also predispose to varicocele formation. Classically, the left gonadal vein differs from its counterpart, by draining into the inferior vena cava via the left renal vein rather than directly, as observed on the right side. It had been proposed that these anatomical factors can lead to increased venous pressures within the left gonadal venous system, thereby leading to varicocele formation. The traditional triad of factors that would predispose to thrombogenesis are: stasis, endothelial injury/factors and hypercoagulability.2 Importantly, we excluded any potential causes of venous obstruction arising from the pelvis, abdomen or retroperitonem and ensured a no...