Varicocele - Disorders of the male genital system

Varicocele

Definition

Varicoceles are dilated veins (pampiniform plexus) along the spermatic cord.

Incidence/prevalence

As common as 1 in 5 post-pubertal males, but often asymptomatic.

Aetiology/pathophysiology

These are the equivalent of varicose veins, due to the valve leaflets becoming incompetent, blood flows back down towards the testis. Varicoceles occur more commonly on the left side due to the perpendicular drainage of the left spermatic vein into the renal vein, which is compressed between the aorta and superior mesenteric artery. Isolated right-sided varicocele should raise the suspicion of a thrombus in the IVC or right renal vein, possibly associated with renal cell carcinoma, because on the right the spermatic vein drains directly into the IVC and should remain competent.

Varioceles are commonly found in men who are infertile, but many also have normal sperm counts. The cause of infertility is not clear. Testicular atrophy is thought to occur due to the slightly raised temperature triggering germ cell apoptosis.

Clinical features

Patients may complain of a dragging sensation or aching pain in the scrotum, particularly on standing. Infertility may be a presenting feature. On palpation there is a soft swelling like ‘a bag of worms’ along the spermatic cord, which is compressible and disappears on lying flat.

Management

Surgery is indicated in boys and young males with asymmetrical growth of the testes/testicular atrophy, and seems to improve testicular growth. However, in infertile men with a varicocele, surgery has not been shown to improve sperm counts. Ligation of the spermatic vein can be either by open or laparoscopic surgery. In older males who no longer wish to have more children, treatment with scrotal support and analgesia may be sufficient.