Varicocele is the dilatation of the pampiniform plexus of veins, a network of many small veins found in the male spermatic cord. It is the most frequently encountered mass of the spermatic cord.
The estimated incidence is at ~15% of the general male population and ~40% of subfertile and infertile men (the most common cause of correctable male infertility).
Varicoceles can be asymptomatic. If symptomatic, presentations include:
- scrotal mass/swelling
- scrotal pain
- testicular atrophy
- infertility or subfertility
The pampiniform veins normally act as heat exchangers, important in the thermoregulation of the testes which is vital for spermatogenesis. A varicocele disturbs this balance and causes heating up of the testis to the normal core body temperature (37ºC), whereas they are normally maintained at a temperature of 35ºC.
A varicocele can be classified as primary or secondary.
Most varicoceles are primary and result from incompetent or congenitally-absent valves in the testicular vein (internal spermatic vein).
The left testicle is affected much more commonly (≈85%) than the right. This may be due to the shorter course of the right testicular vein and its oblique insertion into the IVC which creates less backpressure. Bilateral varicoceles are not uncommon (≈15%), but isolated right varicoceles are rare and should prompt evaluation for a secondary varicocele.
Secondary varicoceles are much less common and result from increased pressure in the testicular vein due to compression (e.g. extrinsic mass), obstruction (e.g. renal vein thrombus), or splenorenal shunting (portal hypertension).
The diagnostic modality of choice:
- dilatation of pampiniform plexus veins >2-3 mm in diameter 3,4
- characteristically have a serpiginous appearance
- there can be flow reversal with the Valsalva maneuver 4
- Doppler ultrasound can be used to grade the degree of reflux
- may show a dilated cluster of enhancing serpiginous veins
Venography, only performed during endovascular treatment, may demonstrate:
- dilated testicular veins
- retrograde flow of contrast towards the scrotum
- dilated pampiniform plexus should not be directly imaged as the testes should be kept out of the x-ray beam
- may be incidentally noted during scrotal MRI
- dilated enhancing serpiginous veins
- signal intensity depends on the velocity of flow
- low flow: intermediate T1 and high T2
- high flow: signal void
- enhancement following gadolinium administration
Treatment and prognosis
This is among one of the surgically-correctable causes of male infertility. Management options include:
A unilateral right-sided varicocele is an uncommon finding, and if found, should prompt an evaluation of the retroperitoneum to exclude a mass obstructing the downstream testicular vein.
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- 3. Chiou RK, Anderson JC, Wobig RK et-al. Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination. Urology. 1997;50 (6): 953-6. doi:10.1016/S0090-4295(97)00452-4 - Pubmed citation
- 4. Lee J, Binsaleh S, Lo K et-al. Varicoceles: the diagnostic dilemma. J. Androl. 2007;29 (2): 143-6. doi:10.2164/jandrol.107.003467 - Pubmed citation
- 5. Vanlangenhove P, Dhondt E, Van Maele G, Van Waesberghe S, Delanghe E, Defreyne L. Internal Spermatic Vein Insufficiency in Varicoceles: A Different Entity in Adults and Adolescents?. AJR. American journal of roentgenology. 205 (3): 667-75. doi:10.2214/AJR.14.14085 - Pubmed
- 6. Lorenc T, Krupniewski L, Palczewski P, Gołębiowski M. The value of ultrasonography in the diagnosis of varicocele. (2016) Journal of ultrasonography. 16 (67): 359-370. doi:10.15557/JoU.2016.0036 - Pubmed
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