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At the time the article was last revised Michael P Hartung had the following disclosures:
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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 are rare in children under the age of ten years, however they may be seen in up to 10-15% adolescents 7.
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 testis 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. In contrast, the left testicular vein has a longer course and inserts into the left renal vein at a right angle. 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 such as retroperitoneal lymphadenopathy or renal 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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