Varicocele

• A varicocoele represents dilatation and tortuosity of the pampiniform venous plexus of the spermatic cord
• The condition is much more common on the left (90%), and results from the different venous drainage of the two sides: on the left, the testicular vein drains into the higher-pressure renal vein, whereas the right testicular vein drains directly into the inferior vena cava.
• Varicocoele is common, affecting about 15% of young adult males.
• Causes:

  • Incompetent calves in testicular vein
  • Obstruction of veins - rarely a left sided varicocele can be caused by renal cell carcinoma obstructing the left renal vein
  • A new right sided varicocele that does not collapse when the patient lies flat warrants urgent investigation - could be due to compression of the vena cava from renal cell carcinoma or other retroperitoneal masses
• Clinical features:

  • Frequently asymptomatic - commonly picked up during infertility screening
  • Usually painless - sometimes have discomfort or a dragging/heavy sensation in scrotum
  • Classically feels like a "bag of worms" within the spermatic cord above the testis
  • Size increases on standing and decreases on lying down
  • Valsalva manoeuvre whilst standing increases dilatation
  • Small testis - can affect testicular growth in adolescents
  • Infertility (around 40% of men with infertility have a varicocele)
• Investigations:

  • Clinical diagnosis however if uncertain can use doppler ultrasound
  • Fertility/semen assessment can be done
  • Most are asymptomatic, do not affect fertility and do not require treatment
• Complications:

  • Testicular damage and atrophy - any evidence of testicle on affected side not growing at same rate as unaffected testicle refer to urology for surgery (recovery of growth seen in most cases)
  • Infertility/subfertility - increased blood flow around testes increases temperature and affects production of sperm
• Referral to urology if:

  • reduced testicular volume
  • Abnormal semen parameters
  • Large symptomatic varicocele
• Urgent referral to urology if:

  • Appears suddenly and is painful
  • Does not drain when lying down (suggests obstruction)
  • Solitary right sided varicocele