Next, locate and palpate the epididymis on the posterior aspect of the testicle. The head and tail should be carefully palpated for tenderness, nodularity, and masses.
The spermatic cord is palpated from the epididymis up to the external abdominal ring. The patient is asked to elevate his penis gently. If the penis is elevated too much, the scrotal skin is reduced, and the examination is more difficult. Hold the scrotum in the midline by placing both your thumbs in front of and both your index fingers on the perineal side of the patient's scrotum. Using both hands, simultaneously palpate both spermatic cords between your thumbs and index fingers as you pull your fingers laterally over the scrotal surface. The most prominent structures in the spermatic cord are the vasa deferens. The vasa are firm cords about 0.08 to 0.15 inches (2 to 4 mm) in diameter and feel like partially cooked spaghetti. The sizes are compared, and tenderness or beading is noted. Absence of the vas deferens on one side is often associated with absence of the kidney on the same side. The technique of spermatic cord palpation is demonstrated in Figure 18-26.
A common enlargement of the spermatic cord resulting from dilatation of the pampiniform plexus is a varicocele. These varicosities are usually on the left side, and the impression on palpation has been likened to feeling a bag of worms. Because the varicocele is gravity dependent, it is usually visible only while the patient is standing or straining. The patient is asked to turn his head and cough while the spermatic cords are held between the examiner's fingers, as indicated previously. A sudden pulsation, especially on the left side, confirms the diagnosis of a varicocele. Although the diagnosis is usually made from palpation, large varicoceles may be discovered on mere inspection, as can be seen in the patient in Figure 18-27.
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