Overview
A varicocele is scrotal swelling due to the abnormal enlargement of the pampiniform plexus of veins in the spermatic cord. This can be due to incompetent valves in the veins or rarely, secondary to tumours obstructing them.
Varicoceles are often asymptomatic but can lead to reduced fertility. They may also be associated with malignancy.
Pathophysiology
Anatomical causes
Around 90% of varicoceles occur on the left side due to anatomical differences in how the right and left spermatic veins drain. The left spermatic vein drains vertically into the larger left renal vein at 90 degrees. It is also longer and these two features increase pressure in it, resulting in an increased likelihood of dilation in the pampiniform plexus of veins in the spermatic cord.
The right spermatic vein drains directly into the vena cava at an oblique angle and therefore, the pressure is generally lower compared to the left, making dilation less likely.
Relation to malignancy
Retroperitoneal or abdominal masses can compress varicoceles, leading to an absence of them diminishing when lying down. If these tumours compress the vena cava, this can cause an isolated right-sided varicocele. This is often associated with right renal cell cancer.
Epidemiology
- Varicoceles affect up to 20% of men from adolescence onwards
- Around 90% of varicoceles are left-sided and a right-sided varicocele is rare
- Around 40% of men with infertility have a varicocele
Risk Factors
- Tall, lean, and underweight build
- Family history
Presentation
Overview
Features include:
- Painless scrotal swelling – left-sided in 90% of cases
- The swelling may be described as a ‘bag of worms’ above the testis:
- Venous dilation is increased when standing or performing the Valsalva manoeuvre and decreases when lying down
- The varicocele cannot usually be palpated when lying down
- Lying down does not decrease dilation or cause the varicocele to reduce, this can suggest obstructive causes (such as tumours)
- Subfertility may be present – around 40%
- Reduced testicular volume
- Scrotal or groin pain is uncommon – around 3%
- May be described as a ‘dragging’ or ‘heavy’ sensation in the scrotum
Diagnosis and Referral
Diagnosis
If referral criteria are not met, the diagnosis of varicocele can be made clinically. If there is uncertainty, an ultrasound scan with colour flow Doppler imaging may be useful (e.g. larger people, thicker scrotal skin, increased amounts of scrotal tissue).
Semen analysis, serum follicle-stimulating hormone (FSH), and testosterone may be tested for subfertility:
- Abnormal sperm production and elevated FSH suggests impaired spermatogenesis
Referral
An urgent referral to a urologist should be made if any of the following apply:
- Varicocele appears suddenly and is painful
- The varicocele does not drain when lying down
- There is an isolated right-sided varicocele
Other referral points include:
- Routinely refer to a urologist if there is pain or discomfort (that is not sudden)
- Refer adolescents if there is concern about reduced testicular volume or parents/carers are concerned and cannot be reassured in primary care
- Refer to urology if there is uncertainty about a scrotal swelling
Differential Diagnoses
Management
Overview
If no underlying causes are present, management is usually conservative as surgery carries a risk of testicular damage. Surgery may be performed if there is pain, to prevent testicular atrophy, or to reduce the risk of infertility (there is a lot of controversy surrounding this suggestion).
Complications
- Pain
- Testicular volume loss and hypogonadism
- Fertility problems – up to 40% of men with primary infertility have a varicocele
Prognosis
- Most varicoceles are asymptomatic and do not affect fertility
