Varicocele

Aka: Varicocele

1. Epidemiology
   1. Present in 20% of all males
   2. Occurs in 30% of infertile men
      1. Most common correctable form of Male Infertility
2. 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
3. Precautions: Red Flags
   1. Sudden onset Varicocele in older man
      1. Left: Assess renal tumor and spermatic vein Occlusion
      2. Right: Assess vena cava obstruction
4. Symptoms
   1. Often asymptomatic
   2. May cause mild pain with vigorous Exercise
   3. Patient finds mass lying posterior and above the Testes
5. Signs
   1. "Bag of worms" superior to the Testicle
   2. Vein dilation and tortuosity
      1. Decreased with patient supine
      2. Increased with patient upright and with Valsalva Maneuver
   3. Left Varicocele most common (80% of cases)
      1. Left testicular vein drains into renal vein
6. 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