Varicocele

Aka: Varicocele

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II. Definitions

  1. Varicocele
    1. Dilated, tortuous pampiniform plexus veins that surround spermatic cord

III. Epidemiology

  1. Incidence increases after Puberty
    1. Not typically present in prepubertal boys
    2. Found in 15% of boys over age 15 years
  2. Present in 20% of all males
  3. Occurs in 35% of men with primary Infertility, and up to 80% with secondary Infertility
    1. Most common correctable form of Male Infertility

IV. Pathophysiology

  1. Abnormal venous tortuosity and dilatation of the pampiniform venous plexus or internal spermatic vein
    1. Gonadal vein valve incompetence
    2. External compression of gonadal vein
  2. Associated Infertility may be due to
    1. Elevated testicular Temperature
    2. Results in decreased spermatogenesis and motility

V. Precautions: Red Flags

  1. Right-sided Varicocele without a left-sided Varicocele
    1. Evaluate for retroperitoneal mass compressing right spermatic vein
  2. Sudden onset Varicocele in older man
    1. Left: Assess renal tumor and spermatic vein Occlusion
    2. Right: Assess vena cava obstruction

VI. Symptoms

  1. Often asymptomatic
  2. May cause mild pain (dull ache or heaviness) exacerbated by standing or vigorous Exercise
  3. Patient finds mass lying posterior and above the Testes

VII. Signs

  1. Perform exam with patient standing to increase Varicocele engorgement
  2. "Bag of worms" superior to the Testicle
  3. Vein dilation and tortuosity within the pampiniform plexus
    1. Decreased with patient supine
    2. Increased with patient upright and with Valsalva Maneuver
  4. Left Varicocele most common (80-90% of cases)
    1. Left spermatic vein drains into renal vein at a 90 degree angle
    2. Right spermatic vein drains into vena cava

VIII. Imaging

  1. Scrotal Ultrasound
    1. Consider for diagnosis confirmation if unclear by exam

IX. Management: Surgical repair

  1. Indication
    1. Persistant symptoms (Dull ache or heavy Sensation)
    2. Abnormal Semen Analysis and Infertility
      1. Surgery may fail to Restore fertility
      2. Evers (2003) Lancet 361:1849-52 [PubMed]
      3. Persad (2021) Cochrane Database Syst Rev (4): CD000479 [PubMed]
  2. Procedures
    1. Surgical ligation of pampiniform plexus
    2. Injected sclerotherapy
    3. Directed embolization via Intervention Radiology

X. References

  1. Cristoforo (2019) Crit Dec Emerg Med 33(10): 15-20
  2. Langan (2022) Am Fam Physician 106(2): 184-9 [PubMed]

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