Varicocele is the enlargement of the pampiniform plexus veins as well as the left internal spermatic vein. It is very similar to varicose veins that occur elsewhere in the body.
It occurs quite commonly, with about 15% of males affected, and about 35-40% in infertile males. It most commonly affects adolescents and young adults.
Pathophysiology
The primary cause is believed to be an increase in hydrostatic pressure within the left internal spermatic vein as well as incompetent/absent valves within the vein or within the pampiniform plexus.
Why might there be increased hydrostatic pressure?
- The left internal spermatic vein inserts into the left renal vein directly. It also inserts at a right angle (90º) which increases the pressure within the vein on the left-hand side. The right internal spermatic vein inserts directly into the inferior vena cava (IVC) at an oblique angle which reduces the pressure on this side.
- The left internal spermatic vein is 8-10cm longer than the right internal spermatic vein.
- There may be compression of the left renal vein by the superior mesenteric artery against the abdominal aorta. This is known as nutcracker syndrome and it manifests with flank pain, proteinuria, haematuria. It also can lead to compression of the left internal spermatic vein → formation of the varicocele.
On rare occasions a varicocele may occur secondary to a retroperitoneal or abdominal mass (such as a renal cell carcinoma) that pushes the internal spermatic vein. It may cause a varicocele that persists when lying down supine or it may present as an isolated right-sided varicocele.
A varicocele itself does not indicate an incompetent valve as it represents a multi-factorial aetiology which remains to be fully understood.
Infertility associated with varicoceles also is unclear but it is believed that an increase in testicular temperature and oxidative stress play a role in testicular atrophy which reduces the size and function of the testicle, further contributing to the infertility. Clinically detectable varicoceles are associated with abnormal gonadotrophin levels, impaired spermatogenesis and histological changes to sperm.
⚠️ Risk factors
- Tall, thin men
- Family history of varicocele
😷 Presentation
Many varicoceles are asymptomatic.
When present, symptoms may include:
- Dull ache or heavy sensation in the scrotum
- Dragging sensation in the scrotum
- Testicular atrophy
- Subfertility or infertility
Findings on examination may include:
- Visibly enlarged or twisted veins in the scrotum - it is often described as a “bag of worms”. It is more prominent when standing and disappears when lying down (unless caused by compression of a retroperitoneal/abdominal mass).
- Asymmetrical testicular size - this is if the varicocele has led to testicular atrophy
🔍 Investigations
It is a clinical diagnosis based on examination and palpation of the scrotum. A Valsalva manoeuvre may make the varicocele more pronounced.
We can perform certain investigations to confirm diagnosis and also investigate complications:
- Doppler ultrasound - to confirm diagnosis.
- Semen analysis - to assess any fertility issues.
- Hormonal tests (such as FSH, GnRH and testosterone) - if there are concerns regarding spermatogenesis and steroidogenesis.
🔢 Classification
Varicoceles may be graded from sub-clinical to grade III depending on the size of the varicocele.
- Sub-clinical - varicocele only detectable on ultrasound.
- Grade I - a small varicocele, palpable only with Valsalva manoeuvre.
- Grade II - a moderate size varicocele, palpable without Valsalva manoeuvre.
- Grade III - a large varicocele visible through the scrotal skin.
🧰 Management
Management of the varicocele is dependant on the patient’s symptoms and their desires for fertility. There are essentially 3 main options for treatment.
- Watchful waiting - this is especially for asymptomatic varicoceles or those that do not pose issues regarding fertility.
- Embolisation - this is a minimally invasive procedure in which the veins of the pampiniform plexus are blocked to prevent blood flow to the veins.
- Surgery - a varicocele repair operation may be performed through open, laparoscopic or robotic procedures in which the varicocele is identified and then excised.
