A varicocele develops due to enlargement of the pampiniform plexus of the spermatic veins. It is the most common cause of scrotal enlargement in postpubertal males. It may appear first during puberty and may become larger over time.
Etiology:
1. Primary varicocele – It is generally left-sided – the left spermatic vein has a longer course and enters the left renal vein at a perpendicular angle. The left renal vein has a higher intravascular pressure than the right renal vein because it’s compressed between the aorta and the superior mesenteric vein, thus producing a “nutcracker effect.” This leads to high pressure in the left spermatic vein, which can dilate and cause incompetent valve leaflets, leading to retrograde flow of blood towards the testis, resulting in the pampiniform plexus dilatation.
2. Secondary varicocele – It can be due to;
- A mass in the retroperitoneal space
- An obstruction to blood flow in the spermatic vein
Clinical presentation
- May be asymptomatic
May present with;
- Painless left-sided- scrotal swelling
- Dull aching pain usually when standing, relieved by recumbency
- Decreased fertility
Physical examination
- Soft strands are palpable in the upper pole- bag of worms
- Swelling increases with the Valsalva maneuver
- Atrophy of the left testicle
- Negative transillumination
Grading;
1. Small- palpable only with Valsalva maneuver
2. Moderate- nonvisible on inspection but visible when standing
3. Large- visible on gross inspection
Investigations
1. Ultrasound- dilated pampiniform vessels
2. Doppler ultrasound- to check the extent of the dilatation
3. Retroperitoneal imaging- for a mass
Management
1. Conservative- most varicoceles do not require intervention.
- Patients may use scrotal support.
2. Invasive methods;
Indications-
- Pain
- Testicular atrophy
- Infertility
- Men<21 years of age- evaluate for testicular atrophy, and those who are postpubertal should go for a semen analysis. Surgical ligation or percutaneous venous embolization should be the option for testicular atrophy and abnormal semen analysis.
- If the semen analysis is normal, monitor with semen analysis every one to two years
- Older men- monitor with semen analysis in those with desired fertility. For those who do not prefer fertility management with NSAIDs and scrotal support
Surgery is the preferred modality of treatment of varicocele. It involves ligating the gonadal vein branches so that retrograde flow doesn’t reach the pampiniform plexus. There are inguinal, subinguinal, or retroperitoneal approaches.
Complications
- Testicular atrophy
- Infertility
