Diagnostic Assessment — Left Varicocele
Example 1 of 1 · fictitious patient (Veteran CQ)
Diagnostic Assessment
Left Varicocele
BOP Code: 80 of 2019 (Varicocoele)
RH Code: 79 of 2019 (Varicocoele)
ADF History
Veteran CQ, date of birth 05 July 1985, Australian Army, Cavalry Scout (Armoured Cavalry crewman), enlisted 21 January 2004, medically discharged 17 October 2016. Operational service: Solomon Islands, 10 May 2006 to 15 November 2006 (non-warlike); Afghanistan, 01 March 2011 to 15 June 2011 (warlike); Middle East Area of Operations, 01 March 2012 to 30 May 2012 (warlike).
Occupational History
A cavalry scout crews armoured reconnaissance vehicles, conducting mounted and dismounted patrols, vehicle maintenance and recovery. The work involves heavy lifting of ammunition, track and wheel components and stores, forceful use of large spanners and recovery equipment, and long periods in a cramped vehicle with repeated jolting.
Crews are exposed to improvised explosive device blasts and fragmentation, vehicle rollovers and blunt trauma to the abdomen and pelvis. Field and deployed postings bring poor sanitation and outbreaks of gastrointestinal infection, and high levels of physical training are expected between patrols.
History
Veteran CQ, a cavalry scout in the Australian Army, sustained fragmentation wounds to the left groin and a left renal injury requiring nephrectomy in an improvised explosive device blast on warlike service in Afghanistan on 14 June 2011, and developed a left varicocele on 20 September 2011, with an arteriovenous fistula and occlusion of the left testicular venous drainage. The varicocele ruptured on 05 June 2012, six days after he returned from warlike service in the Middle East.
Timeline
- 22 Aug 2006 — During non-warlike service in the Solomon Islands the veteran was admitted with bloody diarrhoea, and stool culture grew Shigella flexneri. Three weeks later he developed a swollen right knee, conjunctivitis and low back pain. A medical officer diagnosed reactive arthritis. He was HLA-B27 positive. "Shigella dysentery, reactive arthritis"
- 12 Aug 2009 — A rheumatologist reviewed persistent inflammatory low back pain and morning stiffness of more than one hour since the 2006 reactive arthritis. MRI showed bilateral sacroiliitis with bone marrow oedema and early erosions. Ankylosing spondylitis was diagnosed and he commenced naproxen and a stretching program, later adding adalimumab. "HLA-B27, bilateral sacroiliitis, AS"
- 14 Jun 2011 — On warlike service in Afghanistan his vehicle struck an improvised explosive device. Fragments penetrated the left groin and upper scrotum, and CT at the role 3 hospital showed a shattered left kidney with active bleeding. He underwent emergency left nephrectomy with ligation of the left renal vein, and debridement of the groin wounds. He had earlier presented in April 2011 with recurrent painful mouth and genital ulcers and a red painful left eye. "left nephrectomy, groin fragment wounds"
- 02 Sep 2011 — After aeromedical evacuation and rehabilitation in Australia, a rheumatologist diagnosed Behcet disease on the basis of recurrent oral ulcers, scarring genital ulcers, anterior uveitis confirmed by an ophthalmologist, and a positive pathergy test. Colchicine was commenced. A surgical review of the groin wounds on 26 Jul 2011 had recorded a normal scrotum with no varicocele. "Behcet disease, pathergy positive"
- 23 Sep 2011 — He presented to the garrison health centre with a dragging ache and a soft swelling above the left testis, first noticed on 20 Sep 2011, worse on standing and at the end of the day. Examination showed dilated tortuous veins in the left hemiscrotum, visible when standing and reducing when lying down, with a palpable thrill over the upper scrotum. "bag of worms, palpable thrill"
- 05 Oct 2011 — Scrotal Doppler ultrasound confirmed a grade III left varicocele with veins up to 4.5 mm and continuous reflux, and an arteriovenous fistula between a branch of the left testicular artery and the pampiniform plexus at the site of a retained fragment. CT showed the ligated left renal vein stump with retroperitoneal fibrosis around it. A urologist recommended embolisation of the fistula, which was not performed before his 2012 deployment. "grade III varicocele, AV fistula"
- 05 Jun 2012 — Six days after returning from warlike service in the Middle East he presented to the emergency department with sudden severe left scrotal pain and swelling that began during sexual intercourse that evening. On 02 Jun 2012 he had lifted 40 kg equipment cases while returning deployment stores and noticed bruising of the left scrotum. Ultrasound showed rupture of the varicocele with a large scrotal and spermatic cord haematoma. "ruptured varicocele, scrotal haematoma"
- 20 Aug 2012 — Interventional radiology embolised the arteriovenous fistula, and a urologist performed microsurgical subinguinal varicocelectomy and evacuation of the organised haematoma. Semen analysis in 2013 showed reduced sperm count and motility, and the left testis had reduced in volume from 18 mL to 12 mL. "embolisation and microsurgical varicocelectomy"
Symptoms
At onset the veteran had a dull dragging ache and heaviness in the left hemiscrotum, worse with standing, lifting and exercise and at the end of the day, with a soft swelling above the testis that reduced when he lay down.
After the rupture in June 2012 he had severe scrotal pain, bruising and swelling. Since the repair he reports chronic left testicular pain after exercise and prolonged standing, discomfort in tight clothing and with sitting in vehicles, and reduced fertility, with reduced left testicular volume.
Imaging
- 14 Jun 2011 — CT abdomen and pelvis (role 3 hospital): "Shattered left kidney with active extravasation and perirenal haematoma. Metallic fragments in the left groin and upper scrotum."
- 05 Oct 2011 — Scrotal Doppler ultrasound: "Grade III left varicocele with veins up to 4.5 mm and continuous reflux. Arteriovenous fistula between a branch of the left testicular artery and the pampiniform plexus adjacent to a 6 mm metallic fragment."
- 05 Oct 2011 — CT abdomen: "Absent left kidney. Ligated left renal vein stump with surrounding soft tissue thickening consistent with retroperitoneal fibrosis."
- 05 Jun 2012 — Scrotal ultrasound: "Rupture of the left varicocele with a large heterogeneous haematoma of the scrotum and spermatic cord. Testis perfused."
Onset Date
The most likely date of onset of this condition is 20 Sep 2011.
At that date the veteran was serving full time with an armoured cavalry regiment in Australia, on rehabilitation after his aeromedical evacuation from warlike service in Afghanistan, where he had undergone left nephrectomy and debridement of left groin fragment wounds on 14 Jun 2011.
This date is appropriate because the surgical review of the groin wounds on 26 Jul 2011 recorded a normal scrotum with no varicocele, and he first presented with the swelling on 23 Sep 2011, three days after he noticed it. It falls within continuous full-time service.
For the nephrectomy factor, the one year before onset runs from 20 Sep 2010 to 20 Sep 2011, and the left nephrectomy of 14 Jun 2011 falls within it, 98 days before onset. The occlusion of the left testicular venous drainage arose with the ligation of the left renal vein on 14 Jun 2011, before onset. The arteriovenous fistula from the fragment wound, ankylosing spondylitis diagnosed in 2009 and Behcet disease diagnosed on 02 Sep 2011 were each present on 20 Sep 2011.
For the worsening factors, the varicocele ruptured on 05 Jun 2012. The one year before the worsening runs from 05 Jun 2011 to 05 Jun 2012 and includes the nephrectomy of 14 Jun 2011. The four weeks before the worsening run from 08 May 2012 to 05 Jun 2012, during which he undertook vigorous physical training and patrol duties on warlike service in the Middle East until 30 May 2012. The seven days before the worsening run from 29 May 2012 to 05 Jun 2012 and include the heavy lifting with scrotal haematoma on 02 Jun 2012.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Varicocele (ICD-10 I86.1), a grade III left varicocele with an associated testicular arteriovenous fistula, complicated by rupture in June 2012, under the Statements of Principles concerning varicocoele, Balance of Probabilities No. 80 of 2019 and Reasonable Hypothesis No. 79 of 2019.
A varicocele is an abnormal dilatation and tortuosity of the veins of the pampiniform plexus in the spermatic cord. It occurs when venous drainage from the testis is obstructed or when blood refluxes down an incompetent testicular vein, and it is most common on the left because the left testicular vein drains at a right angle into the left renal vein. It causes a dragging ache and scrotal swelling, and it can reduce testicular size and fertility. Obstruction of the renal vein or testicular vein, and an arteriovenous fistula that pumps arterial blood into the plexus, produce secondary varicoceles. Rarely a varicocele ruptures, causing a scrotal haematoma.
The varicocele followed a blast injury on warlike service in Afghanistan that required left nephrectomy and caused a fragment wound of the spermatic cord. It began on 20 September 2011, was confirmed on Doppler ultrasound on 05 October 2011 and worsened with rupture on 05 June 2012.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
20 September 2011.
When did the veteran first present to a health / medical provider for this condition?
23 September 2011.
When was the condition confirmed / formally diagnosed?
05 October 2011.
When did the veteran first present to you (or your practice) for this condition?
03 September 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made clinically on 23 September 2011 from dilated, tortuous veins of the left pampiniform plexus visible on standing and reducing on lying, and confirmed by scrotal Doppler ultrasound on 05 October 2011, which showed a grade III left varicocele with veins up to 4.5 mm and continuous reflux, and an arteriovenous fistula between a branch of the testicular artery and the pampiniform plexus. A urologist confirmed the diagnosis. This meets the Statement of Principles definition of varicocoele as dilatation of the veins of the pampiniform plexus.
CT on 05 October 2011 showed the ligated left renal vein stump with retroperitoneal fibrosis, confirming obstruction of the testicular venous drainage. Ultrasound on 05 June 2012 confirmed the worsening, with rupture of the varicocele and a scrotal and spermatic cord haematoma.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 20 September 2011, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's operational service: non-warlike service in the Solomon Islands in 2006, where the reactive arthritis that led to ankylosing spondylitis began, warlike service in Afghanistan in 2011, where the blast injury occurred and Behcet disease first appeared, and warlike service in the Middle East in 2012, before the rupture.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Varicocoele, No. 80 of 2019
Causative factors
Factor 9(1): having an occlusion or stenosis of the testicular venous drainage system before the clinical onset of varicocoele; — MET
- The left renal vein, into which the left testicular vein drains, was ligated during the emergency nephrectomy on 14 June 2011 for a blast injury sustained on duty. CT on 05 October 2011 showed the ligated stump surrounded by retroperitoneal fibrosis. This is a complete obstruction of the testicular venous drainage system, present from 14 June 2011, before onset on 20 September 2011.
Factor 9(2): having a nephrectomy within the one year before the clinical onset of the ipsilateral varicocoele; — MET
- The veteran underwent left nephrectomy on 14 June 2011 for a shattered left kidney, and the varicocele is on the same side. The nephrectomy was 98 days before onset, within the one year before onset, from 20 September 2010 to 20 September 2011.
Factor 9(3): having an arterio-venous fistula between any of the arteries supplying the testis and a vein of the pampiniform plexus at the time of the clinical onset of varicocoele; — MET
- Scrotal Doppler ultrasound on 05 October 2011 showed an arteriovenous fistula between a branch of the left testicular artery and the pampiniform plexus, at the site of a 6 mm metallic fragment from the blast of 14 June 2011. A palpable thrill over the upper scrotum was recorded on 23 September 2011. The fistula was present at onset.
Factor 9(4): having ankylosing spondylitis at the time of the clinical onset of varicocoele; — MET
- A rheumatologist diagnosed ankylosing spondylitis on 12 August 2009 from inflammatory back pain, HLA-B27 positivity and bilateral sacroiliitis on MRI. It followed reactive arthritis after Shigella dysentery during service in 2006, and was active and treated with adalimumab at onset on 20 September 2011.
Worsening factors
Factor 9(5): having an occlusion or stenosis of the testicular venous drainage system before the clinical worsening of varicocoele; — MET
- The ligated left renal vein and the surrounding retroperitoneal fibrosis persisted from 14 June 2011 and obstructed the testicular venous drainage before the rupture on 05 June 2012.
Factor 9(6): having a nephrectomy within the one year before the clinical worsening of the ipsilateral varicocoele; — MET
- The left nephrectomy of 14 June 2011 falls within the one year before the rupture of the left varicocele on 05 June 2012, from 05 June 2011 to 05 June 2012.
Factor 9(7): having an arterio-venous fistula between any of the arteries supplying the testis and a vein of the pampiniform plexus at the time of the clinical worsening of varicocoele; — MET
- Embolisation of the fistula, recommended on 05 October 2011, had not been performed, and the fistula was still present at the rupture on 05 June 2012. It was embolised on 20 August 2012.
Factor 9(8): having ankylosing spondylitis at the time of the clinical worsening of varicocoele; — MET
- Ankylosing spondylitis remained active, with a raised CRP and a BASDAI score of 5.2 in May 2012, at the time of the rupture.
Factor 9(9): inability to obtain appropriate clinical management for varicocoele. — MET
- A urologist recommended embolisation of the arteriovenous fistula on 05 October 2011, but the procedure was not scheduled before the veteran deployed to the Middle East on 01 March 2012, and no urological care was available on deployment. The fistula continued to pump arterial blood into the varicocele for eight months, and the varicocele ruptured on 05 June 2012. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Varicocoele, No. 79 of 2019
Causative factors
Factor 9(1): having an occlusion or stenosis of the testicular venous drainage system before the clinical onset of varicocoele; — MET
- The left renal vein was ligated during emergency nephrectomy for the blast injury sustained on warlike service in Afghanistan on 14 June 2011, and retroperitoneal fibrosis formed around the stump. This obstruction of the testicular venous drainage was present before onset on 20 September 2011.
Factor 9(2): having a nephrectomy within the one year before the clinical onset of the ipsilateral varicocoele; — MET
- The left nephrectomy was performed at the role 3 hospital on 14 June 2011 for a renal injury from an improvised explosive device blast on warlike service in Afghanistan, within the one year before onset of the left varicocele on 20 September 2011.
Factor 9(3): having an arterio-venous fistula between any of the arteries supplying the testis and a vein of the pampiniform plexus at the time of the clinical onset of varicocoele; — MET
- The arteriovenous fistula between the left testicular artery branch and the pampiniform plexus was caused by a fragment from the blast on warlike service in Afghanistan on 14 June 2011 and was present at onset.
Factor 9(4): having ankylosing spondylitis at the time of the clinical onset of varicocoele; — MET
- The ankylosing spondylitis developed from reactive arthritis that followed Shigella dysentery on non-warlike service in the Solomon Islands in August 2006, in an HLA-B27 positive person, and was present at onset.
Factor 9(5): having Behcet disease at the time of the clinical onset of varicocoele; — MET
- Recurrent oral and genital ulcers and anterior uveitis first appeared on warlike service in Afghanistan in April 2011, and a rheumatologist diagnosed Behcet disease on 02 September 2011 with a positive pathergy test. It was present at onset on 20 September 2011. Behcet disease causes venous inflammation and thrombosis.
Worsening factors
Factor 9(6): having an occlusion or stenosis of the testicular venous drainage system before the clinical worsening of varicocoele; — MET
- The obstruction from the ligated left renal vein, a consequence of the blast injury on warlike service in Afghanistan, persisted before the rupture on 05 June 2012.
Factor 9(7): having a nephrectomy within the one year before the clinical worsening of the ipsilateral varicocoele; — MET
- The left nephrectomy of 14 June 2011, for the blast injury on warlike service, falls within the one year before the rupture of the left varicocele on 05 June 2012.
Factor 9(8): having an arterio-venous fistula between any of the arteries supplying the testis and a vein of the pampiniform plexus at the time of the clinical worsening of varicocoele; — MET
- The fragment-induced arteriovenous fistula from warlike service in Afghanistan remained untreated during his warlike service in the Middle East and was present at the rupture on 05 June 2012.
Factor 9(9): having ankylosing spondylitis at the time of the clinical worsening of varicocoele; — MET
- Ankylosing spondylitis arising from reactive arthritis on service in the Solomon Islands was active at the rupture, with adalimumab interrupted during his deployment to the Middle East because cold-chain storage was not available.
Factor 9(10): having Behcet disease at the time of the clinical worsening of varicocoele; — MET
- Behcet disease, which first appeared on warlike service in Afghanistan, was active at the rupture, with a flare of oral and genital ulcers recorded in May 2012 on warlike service in the Middle East.
Factor 9(11): undertaking physical activity at a minimum intensity of six METs, for at least six hours per week for at least the four weeks before the clinical worsening of varicocoele; — MET
- On warlike service in the Middle East the veteran undertook unit physical training of running, loaded marches and circuit training, at intensities of 7 to 10 METs, for 8 to 10 hours a week, in addition to dismounted security patrols in armour. This continued throughout the four weeks before the rupture, from 08 May 2012 to his return on 30 May 2012, and he maintained the program on his return until 04 June 2012.
Factor 9(12): for rupture of varicocoele only: (a) having sexual intercourse at the time of the clinical worsening of varicocoele; or (b) having increased intra-abdominal pressure as specified, which has resulted in a scrotal or spermatic cord haematoma, within the seven days before the clinical worsening of varicocoele; — MET
- The worsening was a rupture of the varicocele. The emergency department record of 05 June 2012 documents that the pain and swelling began during sexual intercourse that evening, his first night at home after warlike service in the Middle East. In addition, on 02 June 2012, within the seven days before, he lifted 40 kilogram equipment cases while returning deployment stores and developed bruising and a haematoma of the left scrotum, recorded on the ultrasound of 05 June 2012.
Factor 9(13): inability to obtain appropriate clinical management for varicocoele. — MET
- Embolisation of the arteriovenous fistula was recommended on 05 October 2011 but had not been performed when he deployed on warlike service to the Middle East from 01 March 2012 to 30 May 2012, where no urological or interventional radiology care was available. The untreated varicocele ruptured six days after his return.
The % contribution of the causes is 100% and significant.
Sequelae
The left varicocele is a sequela of the veteran's accepted blast injuries from warlike service in Afghanistan: the left nephrectomy with ligation of the left renal vein and the fragment wound that created the testicular arteriovenous fistula. It has in turn caused chronic left testicular pain, testicular atrophy and reduced fertility, and the rupture required embolisation and surgery.
Unintended Consequence
Met. The obstruction of the testicular venous drainage is an unintended consequence of the ligation of the left renal vein during the emergency nephrectomy performed at a Defence-supported role 3 hospital on 14 June 2011, as treatment of the service injury (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. Embolisation of the arteriovenous fistula was recommended by a urologist on 05 October 2011, but it was not performed before the veteran deployed on warlike service to the Middle East on 01 March 2012, and no urological care, interventional radiology or scrotal ultrasound was available on deployment. The fistula continued to engorge the varicocele for eight months, and it ruptured on 05 June 2012, six days after his return. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the failure to deliver recommended treatment before and during operational service amounts to an inability to obtain appropriate clinical management, and it contributed to the rupture.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 22 Aug 2006, Deployed health record and stool culture, Medical Officer, Solomon Islands
- 12 Aug 2009, Rheumatology consultation and MRI sacroiliac joints, Rheumatologist
- 14 Jun 2011, Trauma admission, CT and operation report, Role 3 hospital, Afghanistan
- 26 Jul 2011, Surgical review, General surgeon
- 02 Sep 2011, Rheumatology consultation, Rheumatologist
- 23 Sep 2011, Outpatient health record, Medical Officer, Garrison health centre
- 05 Oct 2011, Scrotal Doppler ultrasound and CT abdomen, Radiologist
- 05 Oct 2011, Urology consultation, Urologist
- 05 Jun 2012, Emergency department record and scrotal ultrasound, Emergency physician
- 20 Aug 2012, Embolisation report, Interventional radiologist
- 20 Aug 2012, Operation report, microsurgical varicocelectomy, Urologist
- Statement of Principles concerning Varicocoele (Balance of Probabilities) No. 80 of 2019, Repatriation Medical Authority
- Statement of Principles concerning Varicocoele (Reasonable Hypothesis) No. 79 of 2019, Repatriation Medical Authority
