gonad is able to draw the testis up into a position near the pubic tubercle There is no evidence that this causes any harm to the gonad Imaging is not required in this setting, as scrotal ultrasounds are not indicated to locate the testis Scrotal ultrasounds should only be obtained to evaluate for pain or mass Usually, an undescended testis is asymptomatic However, in a position against the abdominal wall, it may be more subject to trauma than when freely mobile in the scrotum The undescended testis also may undergo torsion more easily than a normally descended one The boy who presents with an acutely tender groin mass with an ipsilateral empty scrotum may have torsion of his undescended testis The physician must consider the differential diagnosis of an incarcerated inguinal hernia or acute hydrocele of the cord Prompt surgical treatment may be required Management Testicular malignancy and infertility are increased in the male infant with an uncorrected undescended testis By electron microscopy, it is possible to demonstrate degenerative changes in the undescended testis by year of age so referral to a urologist for orchiopexy is recommended If a retractile testis is identified, and the testis can definitely be brought into the scrotum without tension, then the patient can follow up with his primary care physician for routine monitoring If there is any question, then the patient should be referred to a pediatric urologist Varicocele Clinical Recognition Varicoceles are abnormal dilations of the cremasteric and pampiniform venous plexuses surrounding the spermatic cord ( Fig 119.4 ) They generally present as an asymptomatic scrotal swelling about the time of puberty and are rare in the prepubertal male Almost all are of congenital origin and affect the left testis The anatomic problem is a defect in the valves of the left spermatic vein that drains directly into the left renal vein A higher left renal vein pressure may also play a role Varicoceles affect about 15% of adolescent boys If the varicocele does not disappear when the child lies down, it suggests an obstruction of the left renal vein, and a renal and bladder ultrasound is appropriate Varicoceles are rarely symptomatic; a heavy or tugging sensation is occasionally reported Boys may present with pain or because they notice a different feeling in the scrotum, but they not require urgent treatment The patient should be referred to the urology outpatient clinic for further evaluation and monitoring, although very few patients will ultimately undergo surgical treatment