Varicocele

Epidemiology

The typical patient population affected involves pubescent boys and adults alike, however while it is very uncommon in patients younger than 10 years old it must still be considered as part of your differentials.

Pathophysiology

While there is no exact cause, the common consensus with regards to its pathogenesis states that the condition is a result of venous reflux from the renal vein into the testicular veins.

85-95% of varicoceles occur on the left since the left testicular vein drains into the left renal vein at a 90⁰ angle, making it vulnerable to increased venous reflux from compression by the superior mesenteric artery. On the right-hand side, however, the testicular vein drains directly into the inferior vena cava, making it significantly less vulnerable to reflux. As many as one-third of all males with infertility can have a varicocele, whereas only 10-15% of males with varicoceles have fertility problems.

Clinical features

History – patients usually report a sensation of ‘heaviness’ in the affected scrotum, which worsens over the course of the day as well as during prolonged standing.

Examination – on examination of a patient with suspected varicocele, one notes the dilated veins are more pronounced upon standing and often cannot be palpated when the patient lies flat. In addition, it is described to feel like ‘a bag of worms’ on palpation due to the tortuous and dilated pampiniform plexus.

BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

An image depicting varicocele alongside the normal variant. Note the distended pampiniform veins’ wormy structure.

Classification

Varicoceles can be classified according to their severity. The most commonly used grading system is described below:

Differential diagnosis

There are not many other urological conditions that can be mistaken for a varicocele. However, ensure to rule out the possibility of an intra-abdominal tumour (e.g. renal tumours, retroperitoneal tumours) in high risk patients.

Investigations

1. Semen analysis should be offered to every adult patient due to the associated risks of infertility.
2. Colour flow Doppler ultrasound can be considered if a varicocele cannot be confirmed / ruled out through a clinical examination and also to rule intra-abdominal pathologies as a cause of secondary varicoceles.

Management

There are no specific guidelines for varicocele management and thus it is largely patient-specific. Medical management is limited as not all require treatment, however intervention is indicated in younger patients who either experience pain, want to avoid risks of infertility and the possibility of testicular atrophy. The options for treatment of varicocele are surgical ligation or testicular vein embolization.

Complications

1. Infertility might occur due to impaired local thermoregulation in the testicle, affecting sperm motility and function.
2. Testicular atrophy likely occurs due to pressure atrophy from the dilated testicular veins damaging the seminiferous tubules.

References