# Clinical Cases: Male Reproductive Anatomy and Physiology ## Case 1: Varicocele ### Clinical Image ![Varicocele](case_01_image.jpg) *Source: [Wikipedia - Varicocele](https://en.wikipedia.org/wiki/Varicocele) - CC BY-SA 3.0* ### Case Presentation A 28-year-old male presents to the urology clinic with a 2-year history of left scrotal discomfort and heaviness that worsens with prolonged standing. He and his wife have been trying to conceive for 14 months without success. Physical examination reveals a "bag of worms" palpable in the left scrotum that is more prominent when standing and with Valsalva maneuver. The right scrotum is normal. Testicular volumes are symmetric at 20 mL bilaterally. Scrotal ultrasound with Doppler confirms a left varicocele with retrograde flow during Valsalva. Semen analysis reveals oligoasthenozoospermia: concentration 10 million/mL (normal >15 million/mL), progressive motility 25% (normal >32%), and normal morphology 5%. Serum testosterone is 380 ng/dL (normal), FSH is 6 mIU/mL (normal), and LH is 4 mIU/mL (normal). The diagnosis is grade III left varicocele with secondary infertility. Varicocelectomy is recommended, as surgical repair of varicocele in men with abnormal semen parameters can improve fertility outcomes. ### Key Learning Points - Varicoceles are dilatations of the pampiniform venous plexus and are more common on the left (90%) due to the left testicular vein draining into the left renal vein at a right angle - Varicocele is the most common surgically correctable cause of male infertility, present in 35-40% of infertile men - The increased testicular temperature and potentially retrograde flow of adrenal metabolites impairs spermatogenesis - A new right-sided varicocele or one that does not decompress when supine should raise concern for retroperitoneal pathology such as a renal tumor --- ## Case 2: Hypogonadotropic Hypogonadism (Kallmann Syndrome) ### Clinical Image ![Kallmann Syndrome](case_02_image.jpg) *Source: [Radiopaedia - Kallmann syndrome](https://radiopaedia.org/cases/kallmann-syndrome) - CC BY-NC-SA 3.0* ### Case Presentation An 18-year-old male is referred to endocrinology for delayed puberty. He has not yet developed facial hair, his voice has not deepened, and he has noticed minimal genital development compared to peers. He also reports that he has never been able to smell, even as a child. Physical examination reveals Tanner stage I genital development with prepubertal testes measuring 3 mL bilaterally (normal adult 15-25 mL). There is no facial or axillary hair, and the arm span exceeds height by 6 cm (eunuchoid proportions). Laboratory studies show: testosterone 45 ng/dL (severely low), FSH 1.2 mIU/mL (inappropriately low/normal), LH 0.8 mIU/mL (inappropriately low/normal). Formal olfactory testing confirms anosmia. MRI of the brain reveals absent olfactory bulbs and sulci. The diagnosis is Kallmann syndrome, a form of congenital hypogonadotropic hypogonadism with anosmia due to failure of GnRH neuron migration during embryonic development. Treatment is initiated with testosterone replacement for virilization. The patient is counseled that if he desires fertility in the future, pulsatile GnRH or gonadotropin therapy (hCG + FSH) can induce spermatogenesis. ### Key Learning Points - Kallmann syndrome is caused by failure of GnRH neurons to migrate from the olfactory placode to the hypothalamus during embryonic development - The combination of hypogonadotropic hypogonadism and anosmia is pathognomonic for Kallmann syndrome - Low/normal gonadotropins in the setting of low testosterone indicates secondary (central) hypogonadism - Testosterone replacement achieves virilization but suppresses spermatogenesis; gonadotropin therapy is required for fertility --- ## Case 3: Cryptorchidism ### Clinical Image ![Cryptorchidism](case_03_image.jpg) *Source: [Wikipedia - Cryptorchidism](https://en.wikipedia.org/wiki/Cryptorchidism) - CC BY-SA 4.0* ### Case Presentation A 9-month-old male infant is brought to the pediatric urology clinic after the pediatrician noted an empty right hemiscrotum at the 6-month well-child visit. The parents confirm the right testis has never been palpable in the scrotum. Physical examination confirms an empty right hemiscrotum with no palpable testis in the inguinal canal. The left testis is normally descended. Ultrasound localizes the right testis in the inguinal canal measuring 1.2 cm. Serum testosterone, FSH, and LH are not routinely indicated in unilateral cryptorchidism. The diagnosis is right cryptorchidism (undescended testis). Orchiopexy is scheduled, as surgical correction should be performed between 6-12 months of age to optimize fertility potential and facilitate testicular examination for tumor surveillance. The parents are counseled that cryptorchidism increases the risk of testicular cancer 3-8 fold even after surgical correction, and that the child will need education about testicular self-examination starting in adolescence. ### Key Learning Points - Cryptorchidism (undescended testis) is the most common congenital abnormality of the male genitalia, occurring in 1-3% of full-term male infants - The testes normally descend by 32-36 weeks of gestation; most undescended testes will descend spontaneously by 3-6 months of age - Orchiopexy should be performed by 12-18 months to preserve fertility potential, as the elevated temperature in an undescended position impairs spermatogenesis - Cryptorchidism is associated with increased risk of infertility and testicular cancer (risk persists even after orchiopexy)