Varicocele
Definition
- Abnormal dilation and enlargement of the scrotal venous pampiniform plexus.
- Most commonly occurs on the left side due to anatomical factors.
- Can be asymptomatic or lead to testicular atrophy, pain, and infertility.
Epidemiology
- Affects 15-20% of all males.
- Found in 40% of infertile males.
- Most commonly diagnosed in adolescent and reproductive-age men.
Etiology & Pathophysiology
- Caused by backup of venous blood flow due to:
- Valve failure at the spermatic vein-left renal vein junction.
- Angulation of the spermatic vein.
- Nutcracker effect (compression of left renal vein).
- Leads to increased intratesticular temperature, oxidative stress, and reduced sperm quality.
Clinical Features
- Often asymptomatic but may present with:
- Dull, aching, or throbbing scrotal pain.
- Heaviness in the scrotum.
- Soft mass in the scrotum (“bag of worms” appearance).
- Classified into:
- Large: Visible on inspection.
- Medium: Palpable without Valsalva.
- Small: Palpable only with Valsalva.
- Subclinical: Detected only on ultrasound.
Diagnosis
- Clinical examination : palpation with and without Valsalva maneuver
- Color Doppler ultrasound (gold standard).
- Most surgeons define varicocele as a vein ≥3 mm in diameter at rest.
- Venography for recurrent cases.
- Indications for Additional Imaging (CT Scan)
- Sudden-onset varicocele → Consider retroperitoneal pathology (e.g., renal cell carcinoma).
- Isolated right-sided varicocele → May indicate spermatic vein compression by a tumor.
- Non-reducible varicocele (persistent when supine) → Requires further evaluation with ultrasound or CT scan.
Complications
- Infertility due to impaired sperm count, motility, and morphology.
- Testicular atrophy if untreated.
- Hormonal effects (decreased testosterone levels).
- In older men, varicocele can further impair Leydig cell function, worsening age-related testosterone decline. This can lead
- to hypogonadism, causing symptoms like fatigue, low libido, and decreased muscle mass.
- Scrotal pain (in 2-10% of cases).
- Possible association with renal malignancy if isolated right-sided varicocele.
Management
Conservative
- Observation for asymptomatic cases.
- Scrotal support and analgesia for mild symptoms.
Surgical Indications
- Infertility with abnormal semen parameters.
- Testicular atrophy in adolescents.
- Persistent scrotal pain affecting quality of life.
- Clinically significant varicocele in men planning conception.
Surgical Options
- Microsurgical subinguinal varicocelectomy (preferred technique).
- Laparoscopic varicocelectomy (used in pediatrics, higher recurrence).
- Percutaneous embolization (minimally invasive but less effective than surgery).
- Antegrade scrotal sclerotherapy.
Postoperative Outcomes
- 70% of men have improved semen parameters.
- 40-60% of couples achieve conception post-surgery.
- Improved testosterone levels, particularly in hypogonadal men.
- Semen analysis should be repeated 3-4 months post-surgery.
Prognosis
- Good outcomes with timely surgical intervention.
- Asymptomatic varicoceles do not require treatment.
- Infertility improvement varies based on severity, baseline semen parameters, and patient factors.
Complications of Surgery
- Recurrence (10%).
- Hydrocele formation (5%).
- Testicular atrophy (rare, 5% if artery damaged).
- Scrotal infections (within 3-5 days post-op).
- Persistent pain due to nerve irritation or other causes.
Key Takeaways
- Left-sided varicoceles are most common; right-sided ones require further evaluation.
- Varicocelectomy is indicated for symptomatic varicoceles, infertility, and testicular atrophy.
- Microsurgical varicocelectomy is the gold standard with the highest success rate and lowest recurrence.
- Asymptomatic subclinical varicoceles do not require intervention.
Patient Advice on Varicocele Management
1. Understanding the Condition
- A varicocele is a swollen collection of veins in the scrotum, similar to varicose veins in the legs.
- It is common, affecting up to 20% of men, and is usually harmless.
- It often occurs on the left side due to normal anatomical differences.
2. When to Seek Medical Advice
- If you experience scrotal pain, heaviness, or discomfort.
- If you or your partner are struggling with infertility.
- If you notice testicular shrinkage or an unusual lump in the scrotum.
- If the varicocele is on the right side only (requires further investigation).
3. Conservative (Non-Surgical) Management
- No treatment is needed if the varicocele is small and not causing symptoms.
- Pain relief: Over-the-counter painkillers (paracetamol or ibuprofen) may help.
- Supportive underwear (tight-fitting briefs or an athletic supporter) may reduce discomfort.
- Avoid prolonged standing or heavy lifting if it worsens symptoms.
4. Long-Term Outlook
- Surgery can increase testosterone levels, especially in older men with low testosterone.
- Most varicoceles do not cause major health problems.
- Varicocele repair can improve fertility in about 40-60% of affected men.
Scrotal pain +/- swelling
| Testicular torsion | Irreducible hernia | Torsion of testicular appendage | Epididymo-orchitis | Trauma eg testicular or epididymal rupture | |
| Typical age group | Pubertal (and rarely neonates) | Infants | Pre-pubertal (7-12 years) | <2 years and post-pubertal (rarely pre-pubertal) | – |
| Pain | Severe Usually sudden onsetMay radiate to iliac fossa or thigh | Irritable | Usually sudden onset Usually minimal at rest | Sudden or subacute onset May improve with elevation | May be delayed |
| Swelling | Yes | Yes May extend to scrotum | Yes | Yes | May be delayed |
| Fever | Unusual | Unusual | Unusual | Common | Unusual |
| Nausea and vomiting | Common (90%) | Common | Uncommon | Uncommon | Uncommon |
| Dysuria or discharge | No | No | No | Common | No |
| Gait | Impaired | – | – | – | – |
| Position of testis | High riding or horizontal | – | Normal | – | – |
| Palpation | Tender Thickened spermatic cord | Firm and tender Swelling not reducible | Focal tenderness of upper pole of testis | Tender postero-lateral testis | Tender |
| Oedema crosses midline | No | No | No | Possible | Possible |
| Discoloration | Red/blue Dark in neonate | – | Blue dot sign | Red | Bruising(consider causes, eg NAI) |
| Cremasteric reflex | Usually absent | Usually present | Usually present | Usually present | Usually present |
| Reactive hydrocele | Possible | No | No | Possible | Possible |
Testicular lump differentials
- Average testicular weight 20 g, > 15mL (< 12mL is reduced)
