Varicocoele is the dilatation of 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 general male population and ~40% of subfertile and infertile men (most common cause of correctable male infertility).
Varicocoeles 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 theromoregulation of the testes which is vital for spermatogenesis. A varicocele disturbs this balance and causes heating up of testis to body temperature (37º Celsius), whereas they are normally maintained at a temperature of 35º Celsius.
A varicocoele can be classified as primary or secondary.
Most varicocoeles are primary and result from incompetent or congenitally absent valves in the testicular vein (internal spermatic vein).
The left side testicle is affected much more commonly (≈85%) than the right. This may be due to the shorter course of right testicular vein and its oblique insertion into the IVC which creates less backpressure. Bilateral varicocoeles are not uncommon (≈15%), but isolated right varicocoeles are rare and should prompt evaluation for a secondary varicocele.
Secondary varicocoeles are much less common and result from increased pressure in testicular vein due to compression (e.g. extrinsic mass), obstruction (e.g. renal vein thrombus), or splenorenal shunting (portal hypertension).
Diagnostic modality of choice:
- dilatation of pampiniform plexus veins >2-3 mm diameter 3-4
- characteristically have a serpentine appearance
- there can be flow reversal with the Valsalva manoeuvre 4
- Doppler ultrasound can be used to grade the degree of reflux
- may show a dilated cluster of enhancing serpentine veins
- may be incidentally noted during scrotal MR
- dilated enhancing serpentine veins
- signal intensity depends on velocity of flow
- low flow: intermediate T1 and high T2
- high flow: signal void
- enhancement following gadolinium administration
Venography, only performed during endovascular treatment, will demonstrate
- may show dilated testicular veins
- may show retrograde flow of contrast towards the scrotum
- dilated pampiniform plexus should not be directly imaged as the testes should be kept out of x-ray beam
Treatment and prognosis
This is among one of the surgically correctable causes of male infertility. Management options include:
A right-sided varicocele only is an uncommon finding, and if found, should prompt an evaluation of the retroperitoneum to exclude a mass obstructing the downstream testicular vein.
Ultrasound - testicular and scrotal
- ultrasound (introduction)
testicular and scrotal ultrasound
unilateral testicular lesion
- testicular torsion
- testicular rupture
- germ cell tumours of the testis
- sex cord / stromal tumours of the testis
- bilateral testicular lesion
- paratesticular lesions
- tubular ectasia of the rete testis
- cystadenoma of the rete testis
- testicular sarcoidosis
- testicular tuberculosis
- spermatic cord
- fibrous pseudotumour of the scrotum
- scrotal leiomyosarcoma
- testicular adrenal rest tumours (TARTs)
- tunica vaginalis testis mesothelioma
- splenogonadal fusion
- unilateral testicular lesion
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