Issue: 2020 > Juli > photo quiz

Answer to Photoquiz Sharp abdominal and scrotal pain

W. van ’t Hart, I.J.S.M.L. Vanhooymissen, S.M. Pasha
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The abnormality shown on the CT scan of the abdomen is a thrombosis of the left spermatic vein. Spermatic vein thrombosis is a rarely diagnosed pathology. Often, a spermatic vein thrombosis is an incidental finding upon a CT scan, or identified perioperatively with an incarcerated hernia as preoperative diagnosis.1 Otherwise, patients present with testicular pain or scrotal swelling.2

A majority of thromboses are found in the left spermatic vein. Presumably, this is due to the same anatomical differences that cause more left-sided varicoceles. While the right spermatic vein enters the inferior vena cava directly, the left spermatic vein joins the renal vein, which enters the vena cava superior 8-10 cm higher than the right spermatic vein. This eventually leads to a higher pressure in the left spermatic vein and increased chance of stasis. Also, compression of the renal vein by the superior mesenteric artery and absent or incompetent valves are relatively common and contribute to venous stasis.1,3

Risk factors described are regional malignancies, tumours that affect the testicular venous drainage, varicocele, trauma, hypercoagulable states, systemic diseases, long-distant flights, certain drugs, inguinal hernia surgery, and vigorous exercise.1,2,3,4 There are no available guidelines for spermatic vein thrombosis treatment. Treatment recommendations therefore differ from conservative treatment with anticoagulants or anti-inflammatory drugs to surgically removing the thrombus.2,3,4
A case-control study conducted by Lenz et al. concluded that treatment with anticoagulation for spermatic vein thromboses seems to be indicated, given the recurrence venous thromboembolism rate for spermatic vein thromboses is similar to deep vein thrombosis controls.3
Our patient was treated for the spermatic vein thrombosis with apixaban for three months and recovered fully. The diverticulitis was treated conservatively with painkillers without complications. Because the diverticulitis was identified as the cause of the thrombosis, no further laboratory research to predisposing coagulopathy was carried out.
In conclusion, spermatic vein thrombosis is an uncommon diagnosed pathology which, in our opinion, seems to need treatment with anticoagulants.


All authors declare no conflicts of interest. No funding or financial support was received.


  1. Hashimoto L and Vibeto B. Spontaneous thrombosis of the pampiniform plexus. Scand J Urol Nephrol. 2006;40(3):252-4.
  2. Castillo OA, Diaz M, Vitagliano GJ and Metrebian E. Pulmonary Thromboembolism Secondary to Left Spermatic Vein Thrombosis: A Case Report. Urol Int. 2008;80:217-8.
  3. Lenz CJ, McBane RD, Cohoon KP, et al. Testicular vein thrombosis: Incidence of recurrent venous thromboembolism and survival. Eur J Haematol. 2018;100(1):83-7.
  4. Tekin ZN. Isolated Spermatic Vein Thrombosis. J Coll Physicians Surg Pak. 2019;29(8):780-81