Basics
Description
A varicocele is an abnormal tortuosity and dilation of the testicular veins and the pampiniform venous plexus of the spermatic cord.
Epidemiology
Incidence
- Rare in prepubertal boys, increases with age to approximately 15% in late adolescence and healthy adult population
- 2 " 10 years old, <1%
- 11 " 14 years old, 7.8%
- 15 " 19 years old, 14.1%
- Based on World Health Organization observational study (1992), 15 " 20% of adult varicocele patients have fertility problems.
- Varicocele presents in 25% of men with abnormal semen analysis and 12% of men with normal semen parameters.
- Present in 35 " 40% of males with primary infertility
- Left-sided predominance, 90%
- No racial predilection
Risk Factors
- Exact mechanisms have not been fully elucidated.
- May be related to physiologic changes in puberty, such as rapid testicular growth and increased testicular blood flow
- Associated with increased height and low body mass index
- Increased risk in 1st-degree relatives of patients with a varicocele
Pathophysiology
- Association between varicocele and testicular dysfunction/fertility compromise
- Impaired spermatogenesis: decreased motility, decreased density, and increased number of pathologic sperm forms
- Ipsilateral testicular hypotrophy
- Recent data demonstrates correlation between varicocele grade and testicular hypotrophy, although not observed in prior studies.
- Testicular "catch-up growth " after varicocelectomy
- Catch-up growth in 30 " 50% of patients managed conservatively
- Potential field defect, affecting growth of bilateral testicles
- Exact mechanisms not clearly elucidated " multiple theories:
- Hyperthermia: Varicocele increases intratesticular temperature, likely by interfering with the pampiniform plexus ' ability to provide countercurrent cooling system.
- Potential reflux of renal and adrenal metabolites, causing testicular damage
- Increased production of nitric oxide and reactive oxygen species correlate with severity of varicocele.
- Endocrine abnormalities are found in subset of patients with varicocele, including low testosterone, abnormal response to gonadotropin-releasing hormone (GnRH), and impaired Leydig cell function.
Etiology
- Associated with anatomy of left testicular vein
- Inserts into renal vein at right angle (right testicular vein drains into vena cava)
- Incompetent or absent valves
- Left testicular vein 8 " 10 cm longer than right, with increased pressure
- Increased venous pressure from "nutcracker phenomenon " : compression of left renal vein as it passes between aorta and superior mesenteric artery
Diagnosis
History
- Often asymptomatic and incidentally noted on routine physical exam
- Infertility not common issue in adolescent population
- Associated pain/heaviness/dull ache in 2 " 11% of cases
- Laterality
- Age of onset
- When and how testicular abnormality first detected
- Change in size of varicocele with positioning or Valsalva
- Prior surgery or trauma
- Prior imaging
Physical Exam
- Examine in warm room when patient is supine and standing.
- Palpate at rest and with Valsalva.
- Para- and supratesticular mass; feels like a "bag of worms "
- Assess size and consistency.
- Estimate testicular volume with orchidometer, calipers, or color Doppler ultrasound.
- Right testicle serves as control for left.
- >2 mL or >20% size discrepancy, right > left, is significant.
- Varicocele grade
- Grade 1 (small): palpable only with Valsalva
- Grade 2 (medium): easily palpable but not visible
- Grade 3 (large): visible through scrotal skin
- Varicocele should decompress in supine position.
- Solitary right varicocele or failure of vessels to decompress in supine position raises concern for potential retroperitoneal or abdominal mass.
Diagnostic Tests & Interpretation
- Color Doppler scrotal ultrasound to diagnose varicocele and estimate testicular volume
- Semen analysis in age-appropriate patients
- GnRH simulation test leads to increased FSH and LH response.
- Has not conclusively been shown to be good predictor of postsurgical improvement in adolescents
Differential Diagnosis
- Epididymal cyst/spermatocele
- Testicular mass
- Epididymal mass
- Paratesticular mass
- Inguinal hernia
- Hydrocele
- Cord lipoma
Alert
Secondary varicocele, especially right-sided, can be a clinical indicator of retroperitoneal mass or venous obstruction. It is important to do physical exam standing and in supine position to assess for decompression of varicocele in supine position.
Treatment
- Treatment is not indicated in all children/adolescents with varicocele.
- Annual ultrasound assessment of testicular volume recommended.
- Potential for interobserver variability for imaging
- Spontaneous catch-up growth in some patients managed conservatively.
- 80 " 85% of men with varicocele do not exhibit effect on fertility.
- Definitive treatment is recommended for the following:
- Size discrepancy between right and left testicle of >2 mL or 20%
- Adolescents with abnormal semen analysis and high-grade varicocele
- Adolescents with symptoms: pain, heaviness
- Adolescents with bilateral varicocele
- Treatment options
- Surgical ligation and division of testicular veins (laparoscopic vs. subinguinal approach)
- Testicular artery- and lymphatic-sparing reduces risk of secondary hydrocele.
- Intravenous embolization of testicular veins
Ongoing Care
Follow-up Recommendations
- Persistence should be assessed by surveillance ultrasound 6 months after repair.
- Trans-scrotal US to assess for testicular catch-up growth
- Semen analysis to see if improvement in semen parameters
Prognosis
- After repair, recurrence can occur in 1 " 16% of patients (depending on surgical technique).
Complications
- Recurrent/persistent varicocele
- Secondary hydrocele
- May require surgery if symptomatic
- Testicular hypotrophy/atrophy
- Persistent fertility compromise
Additional Reading
- Evers JH, Collins J, Clarke J. Surgery or embolisation for varicoceles in subfertile men. Cochrane Database Syst Rev. 2009;(3):CD000479. [View Abstract]
- Preston MA, Carnat T, Flood T, et al. Conservative management of adolescent varicoceles: a retrospective review. Urology. 2008;72(1):77 " 80. [View Abstract]
- Robinson SP, Hampton LJ, Koo HP. Treatment strategy for the adolescent varicocele. Urol Clin North Am. 2010;37(2):269 " 278. [View Abstract]
- Serefoglu EC, Saitz TR, La Nasa JA Jr, et al. Adolescent varicocoele management controversies. Andrology. 2013;1(1):109 " 115. [View Abstract]
- Stahl P, Schlegel PN. Standardization and documentation of varicocele evaluation. Curr Opin Neurol. 2011;21(6):500 " 505. [View Abstract]
Codes
ICD09
ICD10
SNOMED
- 46871008 scrotal varices (disorder)
FAQ
- Q: What are long-term benefits of surgical repair of varicoceles?
- A: If varicocele is corrected, testicular catch-up growth can occur when performed in adolescents, as well as decreased risk for infertility. In adult population, 2/3 of patients will have improvement in semen analysis, and 40% of their partners will become pregnant.
- Q: Is there benefit of surgical repair of varicocele after puberty? Will this improve fertility?
- A: Testicular hypotrophy does not improve after adult varicocelectomy. Although it appears to be a progressive process, studies have not clearly demonstrated clear benefit in fertility improvement if corrected in adolescence versus when fertility compromise is diagnosed.
- Q: What happens if a varicocele is left untreated?
- A: There is good evidence to show that when left untreated, a varicocele will continue to affect testicular growth with loss of volume and progressive deterioration in semen analysis.
- Q: What is the risk of recurrence after repair?
- A: Recurrence can occur in 1 " 16% of adolescents, depending on surgical technique.