Varicocele

Aka: Varicocele

1. Definitions
   1. Varicocele
      1. Dilated, tortuous pampiniform plexus veins that surround spermatic cord
2. 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 30% of infertile men
      1. Most common correctable form of Male Infertility
3. Pathophysiology
   1. Abnormal venous tortuosity and dilatation
      1. Pampiniform venous plexus
      2. Internal spermatic vein
   2. Associated Infertility may be due to
      1. Elevated testicular Temperature
      2. Results in decreased spermatogenesis and motility
4. 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
5. 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
6. Signs
   1. "Bag of worms" superior to the Testicle
   2. Vein dilation and tortuosity within the pampiniform plexus
      1. Decreased with patient supine
      2. Increased with patient upright and with Valsalva Maneuver
   3. 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
7. Management: Surgical repair
   1. Indication
      1. Abnormal Semen Analysis and Infertility
         1. Fails to Restore fertility by recent study
            1. Evers (2003) Lancet 361:1849-52 [PubMed]
      2. Persistant symptoms (Dull ache or heavy Sensation)
   2. Procedures
      1. Surgical ligation of pampiniform plexus
      2. Injected sclerotherapy
      3. Directed embolization via Intervention Radiology
8. References
   1. Cristoforo (2019) Crit Dec Emerg Med 33(10): 15-20