Varicocele
Varicocele is dilation of the pampiniform venous plexus and internal spermatic veins, usually left-sided because of the right-angle insertion of the left gonadal vein into the left renal vein, presenting as a painless, non-transilluminating 'bag of worms' scrotal mass that augments with standing or Valsalva and is a leading cause of male infertility. Diagnosis is clinical, confirmed by scrotal Doppler ultrasound when uncertain, and management is conservative (scrotal support, NSAIDs) for asymptomatic cases without testicular atrophy, escalating to surgical ligation or percutaneous embolization for pain, testicular atrophy, or infertility in a patient desiring fertility.
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What this article covers
- Overview
Varicocele is abnormal dilation of the pampiniform venous plexus and internal spermatic veins within the scrotum, caused by increased venous pressure and incompetent venous valves.
- Epidemiology
Varicoceles occur in 15% to 20% of adult men, making them a common finding on routine genitourinary exam.
- Risk factors
Male sex and adulthood, since varicocele is uncommon before puberty and increases with age through mid-adulthood.
- Pathophysiology
Varicocele results from dilation of the pampiniform plexus and internal spermatic veins due to increased venous pressure, most often from incompetent or absent valves within the internal spermatic vein allowing retrograde blood flow.
- Clinical features
A painless or dull, aching scrotal heaviness that worsens with prolonged standing or exertion and improves with lying down is the hallmark presentation, though many varicoceles are entirely asymptomatic and found incidentally.
- Differential diagnosis
Hydrocele: discriminator is a smooth, painless, fluid-filled swelling that transilluminates, unlike the solid, non-transilluminating varicocele; see hydrocele.
- Diagnosis
Varicocele is a clinical diagnosis established by the characteristic "bag of worms" texture on standing palpation that augments with Valsalva and diminishes when supine; imaging is not required when the exam is classic.
- Management
First, determine whether the varicocele is asymptomatic without testicular atrophy or infertility, or symptomatic/complicated (pain, testicular atrophy, or infertility with desire for fertility)…
- Complications
Male infertility, from impaired spermatogenesis attributed to elevated local scrotal temperature and venous stasis, the most clinically important complication.
- Prognosis
The great majority of varicoceles are asymptomatic and require no intervention beyond periodic monitoring.
- Prevention
There is no established primary prevention for varicocele, since it arises from anatomic venous drainage patterns rather than a modifiable risk factor.
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Hydrocele is a painless accumulation of serous fluid within the tunica vaginalis, congenital and communicating in infants or acquired and noncommunicating in adults, diagnosed by transillumination and confirmed with scrotal ultrasound; treatment is observation for asymptomatic disease and hydrocelectomy for persistent or symptomatic cases.
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