Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele

Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele Arash Khameneh Bagheri, Jalaluddin Khoshnevis, Jamshid Sadiqi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3411939/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Scrotal Artero-venus malformation (AVM) is a rare congenital vascular anomaly which is demonstrated as swelling, heaviness, pain and bleeding in inguinal and scrotal area and in some cases may result in azoospermia and infertility. Therefore, this can be misdiagnosed with other usual pathologies of scrotum such as hernia and varicocele. Here we present a case of scrotal AVM which was misdiagnosed as varicocele followed by unnecessary varicocelectomy. Finally, diagnostic angiography confirmed the diagnosis and successful angioembolization was performed for the patient. Scrotal swelling varicocele AVM angiography angioembolization Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Scrotal swelling is a common medical condition. The causes can be benign or malignant such as mass lesions, metastasis, infections or vascular anomalies. Among the vascular etiologies, varicocele is the most common event while arteriovenous malformation (AVM) is the least one [ 1 ]. AVM is a congenital anomaly that is produced by changes in morphologies of vessels with gradual increase in size by child growth and is characterized by hyper-vascularity and excessive arteriovenous connections at the level of nidus [ 2 , 3 ]. The usual sites for AVM are throat, extremities, trunk, intra- and extra-cranial regions of head and neck with the rarest location at scrotal area [ 4 , 5 , 6 ]. AVM often has an audible or tangible bruit and in sonography high systolic blood flow with low Resistive Index (RI) and arterialization of venous flow are detectable. MRI can show extension of AVM into adjacent organs. Angiography demonstrates a rapid shunt of contrast material from feeder arteries to dilated veins through non-developed vascular bed plexus [ 4 ]. The patients with scrotal AVM usually refer to health centers by complaining of scrotal swelling, feeling mass, scrotal heaviness, pain and bleeding. In some severe cases azoospermia with infertility, heart failure and even critical hemorrhage are noted [ 1 ]. Here we present a case of AVM which was wrongly diagnosed and treated as varicocele and then, after accurate diagnosis successful angioembolization was done. Case presentation A 34-year-old man with chief complaints of pain, dysuria, erectile dysfunction and scrotal swelling that increased in size during standing and walking was referred to vascular surgery department. According to patients’ explanation and previous medical records, he was first diagnosed as varicocele and treated by varicocelectomy. He was well for a while but again the signs and symptoms relapsed and even scrotal ulcers were developed. The patient had undergone second operation of varicocelectomy, hydrocelectomy and scrotoplasty. After these operations still the patient had pain that was more severe than before with increase in scrotal secretions and swelling. The third operation of sclerotherapy was performed. After this procedure the pain increased, erectile dysfunction and libido were good at the beginning but later they became worse. In physical examination, bulging was noted in left inguinal and scrotal area with varices at scrotum and base of penis (Fig. 1 ). Thrill was also palpated in scrotum, left inguinal canal and left lower quadrant. The patient was highly suspected for AVM of scrotum and was referred to interventional Radiology Department for angiography and angioembolization. The angiography and angioembolization procedures were done in two separated sessions. The first session was diagnostic angiography. After prep and drape and local anesthesia of the right inguinal area, the right common femoral artery was punctured and a 5F arterial sheet was inserted. Then by a 5F cobra catheter the internal and external left iliac arteries were catheterized separately. During angiography artero-venous malformation was observed in scrotum and base of penis. The AVM had multiple feeders from left internal and external iliac arteries, left internal pudendal, left inferior vesical, scrotal and left perineal arteries. (Fig. 2 – 4 ) After a week, the angioembolization was performed under aseptic condition by insertion of a 6F sheet into the right common femoral artery. Each mentioned feeder of arterial branches of the scrotal AVM were catheterized by micro guide wire (Tenor) and Micro-catheter (Mastero) and were embolized by glue and lipiodole (50%-50% suspension) . No significant reflux of the glue was detected into normal arteries during the operation. The procedure was successfully done with no complication. (Fig. 5 – 6 ) After two days of hospitalization, the swelling of the scrotum and penis base were diminished and patient got free of pain. Follow up examination after 6 months showed mild swelling in left inguinal region however no swelling and dilated veins were noted in the scrotal area. Patient did not complain of pain and was satisfied (Fig. 7 ). Discussion The usual vascular lesion in the scrotum is varicocele while other vascular pathologies like lymphangioma, hemangioma and AVM are very rare [7]. Scrotal AVM accounts for less than 1% of all vascular malformations which can be precisely diagnosed by angiography to demonstrate the feeding arteries, nidus and drainage veins [ 8 ]. In the AVM, the high flow diversion of blood from the tissue can cause various degrees of ischemia and pain [ 9 ]. However, there are also painless cases which present as para-testicular mass or incidental finding during checkup for infertility and sometimes as combination of swelling and infertility [ 10 ]. The increased temperature due to high blood flow may have deleterious effects on spermatogenesis and results in oligo- to azospermia which will get improved following surgery [ 11 ]. The treatments are embolization, sclerotherapy, surgical excision or a combination of them [ 4 , 12 ]. Sclerotherapy is performed to reduce the nidus size and embolization is done before surgical resection in order to decline bleeding risk [7] however embolization can also be utilized as permanent treatment [ 6 ]. Infertility and impotence are major complications as consequences of poor procedural management [7]. The common clinical findings are swelling and palpable mass in scrotal area with pain, hemorrhage and ulceration [ 13 , 14 , 15 ]. Few cases can present with infertility [ 16 , 17 ]. The diagnosis can be done by Doppler ultrasound followed by digital subtraction angiography [ 13 , 14 , 16 ]. Sometimes MRI and CT angiography are also used for the diagnosis of scrotal AVM however they are not very effective for establishment and management of the disease [ 18 , 19 ]. In the treatment of low flow vascular malformations, variable embolization materials such as coil, gelatin, sponge, polyvinyl alcohol particles, onyx, and suspension of butyl cyanoacrylate and lipidol can be used. The choice of these material depends on the size of target vessels, flow velocity and embolization duration (temporary and permanent). The possible complications for embolization procedure are necrosis of skin, bladder or other intra-abdominal organs, arterial perforation and impotence in case of bilateral internal pudendal artery embolization. In cases of skin necrosis, surgery is required to remove the necrotic tissue [ 20 ]. The complications following sclerosant injections are hemolysis which may eventuate to hemoglobinuria, allergy reaction to contrast media and sclerotherapy agents, acute kidney injury in cases of high usage of contrast media. Hematoma and pseudo-aneurysm are considered as local complications in the insertion artery [ 21 ]. No specific complication is noted in our case up to date. Conclusion AVM should be taken in differential diagnosis of patients with scrotal swelling, spontaneous bleeding and scrotal pain. Doppler ultrasound, MRI and CT angiography can be used as diagnostic tools while digital subtraction angiography is the gold standard imaging modality for definitive diagnosis. Embolization of venous compartment of the AVM prior to surgery or alone is considered a good treatment option. Declarations The authors declare no conflict of interests at this case report. All three authors contributed equally in writing, editing and providing the material of this case report. The authors declare no conflict of interests in this case report. The patient provided written informed consent for the procedure and publication. References K. Hubert, J. S. Elder, and G. T. MacLennan, “Benign vascular lesions of the scrotum,” The Journal of Urology, vol. 176, no. 5, p. 2245, 2006. León A ,Palacios J ,Gutierrez P ,Klincovstein J ,Gúzman J . Malformación vascular mixta en escroto: informe de un caso y revisión de la literatura. Acta Pediátrica de México 2012;33(3):112–19 . So WLA, Chaganti J, Waugh R, Ferguson RJ. Management of scrotal arteriovenous malformation with transcatheter embolisation coils and percutaneous sclerotherapy under angiographic guidance. Journal of Medical Imaging and Radiation Oncology 2015;59(4):468–70. doi: 10.1111/1754-9485.12261 . Jaganathan S, Gamanagatti S, Mukund A, Dhar A. Bleeding Scrotal Vascular Lesions: Interventional Management with Transcatheter Embolization. CardioVascular and Interventional Radiology 2011;34(S2):113–16. doi: 10.1007/s00270- 010- 0007- 8 . Mohammad A, Sahyouni W, Almeree T, Alsaid B. Angioembolization of scrotal arteriovenous malformations: a case report and literature review. Case Reports in Vascular Medicine 2020;2020:1–8. doi: 10.1155/2020/8373816 . Zachariah J, Gupta A, Lamba S. Arteriovenous malformation of the scrotum: is preoperative angioembolization a necessity? Indian Journal of Urology 2012;28(3):329. doi: 10.4103/0970-1591.102716 . Zachariah JR, Gupta AK, Lamba S. Arteriovenous malformation of the scrotum: Is preoperative angioembolization a necessity?. Indian J Urol 2012;28:329-34. Konus O, Ilgit E, Yücel C, Özbek E, Önal B. Scrotal arteriovenous malformation and its preoperative embolization. European Radiology 1999;9:425–7. doi: 10.1007/s003300050686 . Sountoulides P, Bantis A, Asouhidou I, Aggelonidou H. Arteriovenous malformation of the spermatic cord as the cause of acute scrotal pain: A case report. J Med Case Reports 2007;1:110. Monoski MA, Gonzales RR, Thomas AJ, Goldstein M. Arteriovenous malformation of scrotum causing virtual azoospermia. Urology 2006;68:203.e5-6. Sule JD, Lemmers MJ, Barry JM. Scrotal arteriovenous malformation: Case report and literature review. J Urol 1993;150:1917-9. Ascoli Marchetti A, Citoni G, Gandini R, Ippoliti A. Case report of a successful multidisciplinary approach to a giant scrotal malformation. International Journal of Surgery Case Reports 2020;69:24–7. doi: 10.1016/j.ijscr.2020.03.019 . W. L. A. So, J. Chaganti, R. Waugh, and R. J. Ferguson,“Management of scrotal arteriovenous malformation with trans catheter embolization coils and percutaneous sclerotherapy under angiographic guidance,” Journal of Medical Imaging and Radiation Oncology, vol. 59, no. 4, pp. 468–470, 2015. D. R. Bezirdjian, P. D. Reznikov, and J. Tisnado, “Transcatheter embolization of an arteriovenous malformation of the scrotum,” Cardiovascular and Interventional Radiology, vol. 12, no. 5, pp. 267–269, 1989. S. H. Choi, J. H. Lee, D. J. Kim, and S. R. Cho, “Scrotal arteriovenous malformation,” Korean Journal of Urology, vol. 46, no. 8, pp. 873–875, 2005. Ö. Konus, E. Ilgit, C. Yücel, E. Özbek, and B. Önal, “Scrotal arteriovenous malformation and its preoperative embolization,” European Radiology, vol. 9, no. 3, pp. 425–427, 1999. G. Bandi, F. J. Bianco, and C. Dhabuwala, “Recurrent scrotal arteriovenous malformation,” Journal of Urology, vol. 171, no. 4, p. 1628, 2004. C. Yilmaz, M. Arslan, and M. Arslan, “Intrascrotal arteriovenous malformation simulating varicocele,” American Journal of Roentgenology, vol. 192, no. 6, article W351, 2009. J. R. Zachariah, A. K. Gupta, and S. Lamba, “Arteriovenous malformation of the scrotum: is preoperative angioembolization a necessity?,” Indian Journal of Urology, vol. 28, no. 3, pp. 329–334, 2012. J. I. Bilbao, A. Martínez-Cuesta, F. Urtasun, and O. Cosín, “Complications of embolization,” Seminars in Interventional Radiology, vol. 23, no. 2, pp. 126–142, 2006. J. J. Marler and J. B. Mulliken, “Current management of hemangiomas and vascular malformations,” Clinics in Plastic Surgery, vol. 32, no. 1, pp. 99–116, ix, 2005. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3411939","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":246286130,"identity":"06e63804-0100-4296-96c3-359e2e5f56a7","order_by":0,"name":"Arash Khameneh Bagheri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYJACZsY/bHIMDDwkaWngMyZZi1xiA9Fa+Gcffvy5cIdZ+objZw8++MBgJ6fbQECLxLk0M+mZZ9JyN5zJSzacwZBsbHaAkDVnGMyYediO5W44kGMmzcNwIHEbIS3yZ9g/f+Zh+59ucP4NkVoMzvAYSPO2sSUY3CDWFsMzPGXSPGfYDGfeeGNsOMOACL/InWHf/Jmngk2e73yO4YMPFXZyhL0PAwpglQbEKgcB+QZSVI+CUTAKRsGIAgBeMT+tRts3ngAAAABJRU5ErkJggg==","orcid":"","institution":"Shahid Beheshti University of Medical Sciences School of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Arash","middleName":"Khameneh","lastName":"Bagheri","suffix":""},{"id":246286131,"identity":"7276df56-4168-412e-8881-23a8dc9be702","order_by":1,"name":"Jalaluddin Khoshnevis","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jalaluddin","middleName":"","lastName":"Khoshnevis","suffix":""},{"id":246286132,"identity":"deb8da60-3ef9-4316-a0e2-24e2bf06ffbd","order_by":2,"name":"Jamshid Sadiqi","email":"","orcid":"","institution":"Mellat Medical Complex","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jamshid","middleName":"","lastName":"Sadiqi","suffix":""}],"badges":[],"createdAt":"2023-10-05 03:18:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3411939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3411939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46089388,"identity":"c2b89260-f418-4c4f-a8fe-1802e0b63321","added_by":"auto","created_at":"2023-11-08 13:32:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":433313,"visible":true,"origin":"","legend":"\u003cp\u003eSwelling is seen in left inguinal and scrotum with multiple varices at scrotum and base of penis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/c1c20de4bad189573ef4e843.png"},{"id":46089386,"identity":"5e453ea9-ac1f-48a3-84fe-1c950189216a","added_by":"auto","created_at":"2023-11-08 13:32:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":94893,"visible":true,"origin":"","legend":"\u003cp\u003eArterial phase of left internal iliac artery angiography shows AV malformation in the left pudendal and scrotal area\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/debb7ca8b6315af0bcdecfa6.png"},{"id":46089384,"identity":"c97de590-62f0-4135-9e02-d235ecc58fbe","added_by":"auto","created_at":"2023-11-08 13:32:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":99332,"visible":true,"origin":"","legend":"\u003cp\u003eNidus phase of left internal iliac artery angiography shows crowding AV malformation in the left pudendal and scrotal area\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/7893d1dfb4a4f0196f7b3ef2.png"},{"id":46089787,"identity":"71a43f32-6f18-4be6-b171-35a52b83db88","added_by":"auto","created_at":"2023-11-08 13:40:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":126029,"visible":true,"origin":"","legend":"\u003cp\u003eVenus phase angiography of left internal iliac vein shows the AV malformation and dilated aneurysmal drainage vein which is sequela of previous varicocelectomy. This bulging was also mistaken for hernia.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/6a348f9ad09f397149021455.png"},{"id":46089788,"identity":"60bdfa16-753d-4f61-b8e6-7c427de9614f","added_by":"auto","created_at":"2023-11-08 13:40:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":249903,"visible":true,"origin":"","legend":"\u003cp\u003eCyanoacrylate glue embolization of left scrotal AVM\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/b273e64c73f30b9d536ab15a.png"},{"id":46089385,"identity":"5c1bd0e6-e5f1-462d-91ef-ef0d566ce664","added_by":"auto","created_at":"2023-11-08 13:32:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":115481,"visible":true,"origin":"","legend":"\u003cp\u003ePost glue embolization angiography of left scrotal AVM\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/27c5d3d53ca7489872a6a441.png"},{"id":46089389,"identity":"698026c2-6183-4689-96ff-14da764fb20f","added_by":"auto","created_at":"2023-11-08 13:32:45","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":401731,"visible":true,"origin":"","legend":"\u003cp\u003eFollow up after 6 months shows no swelling in scrotal area with no complication, just mild swelling is seen in left inguinal region)\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/50d4fb5d7eaeb9c1c73cbf88.png"},{"id":46931480,"identity":"d0e64353-a92d-4a25-bc25-78170bfb224a","added_by":"auto","created_at":"2023-11-22 16:37:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1548496,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3411939/v1/38c3850f-5e85-4fed-9fe5-df73283380c2.pdf"}],"financialInterests":"","formattedTitle":"Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele","fulltext":[{"header":"Introduction","content":"\u003cp\u003eScrotal swelling is a common medical condition. The causes can be benign or malignant such as mass lesions, metastasis, infections or vascular anomalies. Among the vascular etiologies, varicocele is the most common event while arteriovenous malformation (AVM) is the least one [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. AVM is a congenital anomaly that is produced by changes in morphologies of vessels with gradual increase in size by child growth and is characterized by hyper-vascularity and excessive arteriovenous connections at the level of nidus [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe usual sites for AVM are throat, extremities, trunk, intra- and extra-cranial regions of head and neck with the rarest location at scrotal area [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. AVM often has an audible or tangible bruit and in sonography high systolic blood flow with low Resistive Index (RI) and arterialization of venous flow are detectable. MRI can show extension of AVM into adjacent organs. Angiography demonstrates a rapid shunt of contrast material from feeder arteries to dilated veins through non-developed vascular bed plexus [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patients with scrotal AVM usually refer to health centers by complaining of scrotal swelling, feeling mass, scrotal heaviness, pain and bleeding. In some severe cases azoospermia with infertility, heart failure and even critical hemorrhage are noted [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHere we present a case of AVM which was wrongly diagnosed and treated as varicocele and then, after accurate diagnosis successful angioembolization was done.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 34-year-old man with chief complaints of pain, dysuria, erectile dysfunction and scrotal swelling that increased in size during standing and walking was referred to vascular surgery department. According to patients\u0026rsquo; explanation and previous medical records, he was first diagnosed as varicocele and treated by varicocelectomy. He was well for a while but again the signs and symptoms relapsed and even scrotal ulcers were developed. The patient had undergone second operation of varicocelectomy, hydrocelectomy and scrotoplasty. After these operations still the patient had pain that was more severe than before with increase in scrotal secretions and swelling. The third operation of sclerotherapy was performed. After this procedure the pain increased, erectile dysfunction and libido were good at the beginning but later they became worse.\u003c/p\u003e \u003cp\u003eIn physical examination, bulging was noted in left inguinal and scrotal area with varices at scrotum and base of penis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Thrill was also palpated in scrotum, left inguinal canal and left lower quadrant. The patient was highly suspected for AVM of scrotum and was referred to interventional Radiology Department for angiography and angioembolization. The angiography and angioembolization procedures were done in two separated sessions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe first session was diagnostic angiography. After prep and drape and local anesthesia of the right inguinal area, the right common femoral artery was punctured and a 5F arterial sheet was inserted. Then by a 5F cobra catheter the internal and external left iliac arteries were catheterized separately. During angiography artero-venous malformation was observed in scrotum and base of penis. The AVM had multiple feeders from left internal and external iliac arteries, left internal pudendal, left inferior vesical, scrotal and left perineal arteries. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter a week, the angioembolization was performed under aseptic condition by insertion of a 6F sheet into the right common femoral artery. Each mentioned feeder of arterial branches of the scrotal AVM were catheterized by micro guide wire (Tenor) and Micro-catheter (Mastero) and were embolized by glue and lipiodole \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(50%-50% suspension)\u003c/span\u003e. No significant reflux of the glue was detected into normal arteries during the operation. The procedure was successfully done with no complication. (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter two days of hospitalization, the swelling of the scrotum and penis base were diminished and patient got free of pain. Follow up examination after 6 months showed mild swelling in left inguinal region however no swelling and dilated veins were noted in the scrotal area. Patient did not complain of pain and was satisfied (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe usual vascular lesion in the scrotum is varicocele while other vascular pathologies like lymphangioma, hemangioma and AVM are very rare [7].\u003c/p\u003e \u003cp\u003eScrotal AVM accounts for less than 1% of all vascular malformations which can be precisely diagnosed by angiography to demonstrate the feeding arteries, nidus and drainage veins [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the AVM, the high flow diversion of blood from the tissue can cause various degrees of ischemia and pain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, there are also painless cases which present as para-testicular mass or incidental finding during checkup for infertility and sometimes as combination of swelling and infertility [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The increased temperature due to high blood flow may have deleterious effects on spermatogenesis and results in oligo- to azospermia which will get improved following surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe treatments are embolization, sclerotherapy, surgical excision or a combination of them [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Sclerotherapy is performed to reduce the nidus size and embolization is done before surgical resection in order to decline bleeding risk [7] however embolization can also be utilized as permanent treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Infertility and impotence are major complications as consequences of poor procedural management [7].\u003c/p\u003e \u003cp\u003eThe common clinical findings are swelling and palpable mass in scrotal area with pain, hemorrhage and ulceration [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Few cases can present with infertility [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The diagnosis can be done by Doppler ultrasound followed by digital subtraction angiography [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Sometimes MRI and CT angiography are also used for the diagnosis of scrotal AVM however they are not very effective for establishment and management of the disease [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In the treatment of low flow vascular malformations, variable embolization materials such as coil, gelatin, sponge, polyvinyl alcohol particles, onyx, and suspension of butyl cyanoacrylate and lipidol can be used. The choice of these material depends on the size of target vessels, flow velocity and embolization duration (temporary and permanent). The possible complications for embolization procedure are necrosis of skin, bladder or other intra-abdominal organs, arterial perforation and impotence in case of bilateral internal pudendal artery embolization. In cases of skin necrosis, surgery is required to remove the necrotic tissue [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe complications following sclerosant injections are hemolysis which may eventuate to hemoglobinuria, allergy reaction to contrast media and sclerotherapy agents, acute kidney injury in cases of high usage of contrast media. Hematoma and pseudo-aneurysm are considered as local complications in the insertion artery [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. No specific complication is noted in our case up to date.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAVM should be taken in differential diagnosis of patients with scrotal swelling, spontaneous bleeding and scrotal pain. Doppler ultrasound, MRI and CT angiography can be used as diagnostic tools while digital subtraction angiography is the gold standard imaging modality for definitive diagnosis. Embolization of venous compartment of the AVM prior to surgery or alone is considered a good treatment option.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare no conflict of interests at this case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll three authors contributed equally in writing, editing and providing the material of this case report.\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interests in this case report. The patient provided written informed consent for the procedure and publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eK. Hubert, J. S. Elder, and G. T. MacLennan, \u0026ldquo;Benign vascular lesions of the scrotum,\u0026rdquo; The Journal of Urology, vol. 176, no. 5, p. 2245, 2006.\u003c/li\u003e\n\u003cli\u003eLe\u0026oacute;n A ,Palacios J ,Gutierrez P ,Klincovstein J ,G\u0026uacute;zman J . Malformaci\u0026oacute;n vascular mixta en escroto: informe de un caso y revisi\u0026oacute;n de la literatura. Acta Pedi\u0026aacute;trica de M\u0026eacute;xico 2012;33(3):112\u0026ndash;19 .\u003c/li\u003e\n\u003cli\u003eSo WLA, Chaganti J, Waugh R, Ferguson RJ. Management of scrotal arteriovenous malformation with transcatheter embolisation coils and percutaneous sclerotherapy under angiographic guidance. Journal of Medical Imaging and Radiation Oncology 2015;59(4):468\u0026ndash;70. doi: 10.1111/1754-9485.12261 .\u003c/li\u003e\n\u003cli\u003eJaganathan S, Gamanagatti S, Mukund A, Dhar A. Bleeding Scrotal Vascular Lesions: Interventional Management with Transcatheter Embolization. CardioVascular and Interventional Radiology 2011;34(S2):113\u0026ndash;16. doi: 10.1007/s00270- 010- 0007- 8 .\u003c/li\u003e\n\u003cli\u003eMohammad A, Sahyouni W, Almeree T, Alsaid B. Angioembolization of scrotal arteriovenous malformations: a case report and literature review. Case Reports in Vascular Medicine 2020;2020:1\u0026ndash;8. doi: 10.1155/2020/8373816 .\u003c/li\u003e\n\u003cli\u003eZachariah J, Gupta A, Lamba S. Arteriovenous malformation of the scrotum: is preoperative angioembolization a necessity? Indian Journal of Urology 2012;28(3):329. doi: 10.4103/0970-1591.102716 .\u003c/li\u003e\n\u003cli\u003eZachariah JR, Gupta AK, Lamba S. Arteriovenous malformation of the scrotum: Is preoperative angioembolization a necessity?. Indian J Urol 2012;28:329-34.\u003c/li\u003e\n\u003cli\u003eKonus O, Ilgit E, Y\u0026uuml;cel C, \u0026Ouml;zbek E, \u0026Ouml;nal B. Scrotal arteriovenous malformation and its preoperative embolization. European Radiology 1999;9:425\u0026ndash;7. doi: 10.1007/s003300050686 .\u003c/li\u003e\n\u003cli\u003eSountoulides P, Bantis A, Asouhidou I, Aggelonidou H. Arteriovenous malformation of the spermatic cord as the cause of acute scrotal pain: A case report. J Med Case Reports 2007;1:110.\u003c/li\u003e\n\u003cli\u003eMonoski MA, Gonzales RR, Thomas AJ, Goldstein M. Arteriovenous malformation of scrotum causing virtual azoospermia. Urology 2006;68:203.e5-6.\u003c/li\u003e\n\u003cli\u003eSule JD, Lemmers MJ, Barry JM. Scrotal arteriovenous malformation: Case report and literature review. J Urol 1993;150:1917-9.\u003c/li\u003e\n\u003cli\u003eAscoli Marchetti A, Citoni G, Gandini R, Ippoliti A. Case report of a successful multidisciplinary approach to a giant scrotal malformation. International Journal of Surgery Case Reports 2020;69:24\u0026ndash;7. doi: 10.1016/j.ijscr.2020.03.019 .\u003c/li\u003e\n\u003cli\u003eW. L. A. So, J. Chaganti, R. Waugh, and R. J. Ferguson,\u0026ldquo;Management of scrotal arteriovenous malformation with trans catheter embolization coils and percutaneous sclerotherapy under angiographic guidance,\u0026rdquo; Journal of Medical Imaging and Radiation Oncology, vol. 59, no. 4, pp. 468\u0026ndash;470, 2015.\u003c/li\u003e\n\u003cli\u003eD. R. Bezirdjian, P. D. Reznikov, and J. Tisnado, \u0026ldquo;Transcatheter embolization of an arteriovenous malformation of the scrotum,\u0026rdquo; Cardiovascular and Interventional Radiology, vol. 12, no. 5, pp. 267\u0026ndash;269, 1989.\u003c/li\u003e\n\u003cli\u003eS. H. Choi, J. H. Lee, D. J. Kim, and S. R. Cho, \u0026ldquo;Scrotal arteriovenous malformation,\u0026rdquo; Korean Journal of Urology, vol. 46, no. 8, pp. 873\u0026ndash;875, 2005.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;. Konus, E. Ilgit, C. Y\u0026uuml;cel, E. \u0026Ouml;zbek, and B. \u0026Ouml;nal, \u0026ldquo;Scrotal arteriovenous malformation and its preoperative embolization,\u0026rdquo; European Radiology, vol. 9, no. 3, pp. 425\u0026ndash;427, 1999.\u003c/li\u003e\n\u003cli\u003eG. Bandi, F. J. Bianco, and C. Dhabuwala, \u0026ldquo;Recurrent scrotal arteriovenous malformation,\u0026rdquo; Journal of Urology, vol. 171, no. 4, p. 1628, 2004.\u003c/li\u003e\n\u003cli\u003eC. Yilmaz, M. Arslan, and M. Arslan, \u0026ldquo;Intrascrotal arteriovenous malformation simulating varicocele,\u0026rdquo; American Journal of Roentgenology, vol. 192, no. 6, article W351, 2009.\u003c/li\u003e\n\u003cli\u003eJ. R. Zachariah, A. K. Gupta, and S. Lamba, \u0026ldquo;Arteriovenous malformation of the scrotum: is preoperative angioembolization a necessity?,\u0026rdquo; Indian Journal of Urology, vol. 28, no. 3, pp. 329\u0026ndash;334, 2012.\u003c/li\u003e\n\u003cli\u003eJ. I. Bilbao, A. Mart\u0026iacute;nez-Cuesta, F. Urtasun, and O. Cos\u0026iacute;n, \u0026ldquo;Complications of embolization,\u0026rdquo; Seminars in Interventional Radiology, vol. 23, no. 2, pp. 126\u0026ndash;142, 2006.\u003c/li\u003e\n\u003cli\u003eJ. J. Marler and J. B. Mulliken, \u0026ldquo;Current management of hemangiomas and vascular malformations,\u0026rdquo; Clinics in Plastic Surgery, vol. 32, no. 1, pp. 99\u0026ndash;116, ix, 2005. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Scrotal swelling, varicocele, AVM, angiography, angioembolization","lastPublishedDoi":"10.21203/rs.3.rs-3411939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3411939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eScrotal Artero-venus malformation (AVM) is a rare congenital vascular anomaly which is demonstrated as swelling, heaviness, pain and bleeding in inguinal and scrotal area and in some cases may result in azoospermia and infertility. Therefore, this can be misdiagnosed with other usual pathologies of scrotum such as hernia and varicocele. Here we present a case of scrotal AVM which was misdiagnosed as varicocele followed by unnecessary varicocelectomy. Finally, diagnostic angiography confirmed the diagnosis and successful angioembolization was performed for the patient.\u003c/p\u003e","manuscriptTitle":"Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-08 13:32:40","doi":"10.21203/rs.3.rs-3411939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3891c6dc-b256-4dba-93c5-1bf01d5891e2","owner":[],"postedDate":"November 8th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-11-22T16:29:22+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-08 13:32:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3411939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3411939","identity":"rs-3411939","version":["v1"]},"buildId":"re_ckhLnmML6MCF96OHNJ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}