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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Ontology: Varicocele (C0042341)

Definition (MSH) A condition characterized by the dilated tortuous veins of the SPERMATIC CORD with a marked left-sided predominance. Adverse effect on male fertility occurs when varicocele leads to an increased scrotal (and testicular) temperature and reduced testicular volume.
Concepts Disease or Syndrome (T047)
MSH D014646
ICD9 456.4
ICD10 I86.1
SnomedCT 155480003, 195480007, 51070004, 46871008
LNC LA14531-0
English Varicocele, Varicoceles, Varicocoele, varicocele (physical finding), varicocele, scrotal varices (diagnosis), scrotal varices, varicocele (diagnosis), scrotal varicocele (diagnosis), scrotal varicocele, Pampinocele, Scrotal varicose veins, Varicole, Varicocele [Disease/Finding], varicose veins scrotum, varicole, scrotum varicose vein, Varicose veins;scrotum, scrotal varicose veins, varicoles, varicoceles, scrotum varicose veins, Scrotal varices, Scrotal varices - varicocele, Scrotal varices (disorder), Varicocele (disorder), scrotum; varix, spermatic cord; varicocele, varices; scrotum, varicocele; spermatic cord, Varicocele [Ambiguous], varicocoele, varicose veins on the scrotum
Italian Vene dello scroto varicose, Pampinocele, Varici scrotali, Varicosi scrotale, Varicocele
Dutch scrotale varices, varicocele, scrotum; varix, varices; scrotum, varicokèle; zaadstreng, zaadstreng; varicokèle, balzak spataderen, varicokèle, Scrotale varices, Varicocele, Varicokèle
French Varices scrotales, Varices des veines scrotales, Varicocèle
German Pampinocele, Varicole, Skrotumvarizen, Varikozele
Portuguese Varizes escrotais, Varicocelo, Veias varicosas do escroto, Varicocele
Spanish Varices escrotales, Pampinocele, varicocele (trastorno), varicocele, várices escrotales (trastorno), várices escrotales, Venas varicosas escrotales, Varicocele
Japanese 陰嚢静脈瘤, 精索静脈瘤, セイサクジョウミャクリュウ, インノウジョウミャクリュウ
Swedish Pungåderbråck
Finnish Varikoseele
Czech Varikokéla, Pampinokéla, Skrotální varixy, Varikózní žíly skrota, varikokéla
Korean 음낭 정맥류
Polish Żylaki powrózka nasiennego
Hungarian Plexus pampinoformis sérve, scrotal varixok, Scrotalis varicosus venák, Varicosus, Varicocele
Norwegian Varikocele, Årebrokk i pungen