Varicocoele

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. 

Aetiology

A varicocoele can be classified as primary or secondary.

Primary varicocoele 

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 varicocoele

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). 

Variants
Ultrasound

Diagnostic modality of choice:

CT
  • may show a dilated cluster of enhancing serpentine veins
MRI
  • 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
Angiography  

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

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.


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Article Information

rID: 4631
Section: Pathology
Synonyms or Alternate Spellings:
  • Varicocele
  • Varicocoeles
  • Varicoceles
  • Scrotal varicocele
  • Scrotal varicoceles
  • Scrotal varicocoeles
  • Scrotal varicocoele

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