Varicocele

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Varicocele is an abnormal enlargement of the veins in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Up-ward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a varicocele.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus, which is the network of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis and vas deferens, and then into the spermatic cord. This network of veins coalesces into the gonadal, or testicular, vein. The right gonadal vein drains into the inferior vena cava, while the left gonadal vein drains into the left renal vein at right angle to the renal vein, which then drains into the inferior vena cava.

The small vessels of the pampiniform plexus normally range from 0.5-1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele.

The idiopathic varicocele occurs when the valves within the veins along the spermatic cord don’t work properly. This is essentially the same process as varicose veins, which are common in the legs. This results in backflow of blood into the pampiniform plexus and causes increased pressures, ultimately leading to damage to the testicular tissue.

Varicoceles usually develop slowly and may not have any symptoms. There are most frequently diagnosed when a patient is 15-25 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males.

98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein runs vertically up to the renal vein, while the right testicular vein drains directly into the vena cava. Isolated right sided varicoceles are rare, and should prompt evaluation for an abdominal or pelvic mass (see secondary varicocele, below).

A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a varicocele is newly diagnosed in a patient older than 40 years of age. One non-malignant cause of a secondary varicocele is the so-called “nut-cracker SMA” (superior mesenteric artery), a condition in which the superior mesenteric artery compresses the left renal vein, causing increased pressures there to be transmitted retrograde into the left pampiniform plexus.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

A varicocele forms when valves inside the veins along the spermatic cord prevent blood from flowing properly. This causes the blood to back up, leading to swelling and widening of the veins. (This is essentially the same process that leads to varicose veins, which are common in the legs.)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Varicoceles usually develop slowly. They are more common in men ages 15 – 25 and are most often seen on the left side of the scrotum. Varicoceles are often the cause of infertility in men.

The sudden appearance of a varicocele in an older man may be caused by a kidney tumor, which can block blood flow to a vein. This is more common on the left side than the right.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Varicocele may lead to infertility. Complications from treatment may include:

• Atrophic testis
• Blood clot formation
• Infection
• Injury to the scrotal tissue or nearby blood vessel

A varicocele is usually harmless and sometimes requires no treatment. If surgery is required because of infertility or testicular atrophy, the outlook is usually excellent. Removal of varicocele can lead to normal testicular temperatures and an increased sperm production.

Whether or not a varicocele causes infertility is a contentious issue. Recent research suggests that there may be no improvement in fertility after treating a varicocele with surgery; indeed, the research implies that there may not even be a reliable causal link between the presence of a varicocele and infertility in males ^[1].

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