Testicular Varicocele

A varicocele is of diagnostic importance as it is implicated in nearly 40% of cases of male infertility.  It is due to retrograde flow of blood into the internal spermatic vein that progresses to a dilation of the peritesticular pampiniform plexus.  This occurs on the left side in 85% of cases due to incompetence of the valve between the internal spermatic vein and the renal vein where an increased angle of insertion causes greater valve insufficency.  If far enough advanced, the physical appearance of the scrotum becomes similar to the proverbial ‘bag of worms’ picture.

Up to 10-15% of men in the general population develop a varicocele.  Infertility from varicoceles are a result of an increased amount of blood present in the scrotum and a resultant increase in the temperature of the scrotal sac and testicles; this temperature increase yields poor motility and count of sperm. Generally the testicles are two degrees cooler than the abdominal cavity, however a varicocele normalizes this necessary physiologic difference.

Varicoceles rarely produce symptoms, and are thus not usually repaired unless they result in infertility.  In this case, there are several treatment options.

Diagnostics: Current practice favors high resolution color flow doppler US as an inital diagnostic modality. Other modalities used to diagnose varicocele include venography, radionuclide angiography, and thermography, but are more invasive and time intensive. Varicoceles have a characteristic "reverse flow pattern" on doppler US (i.e. the color changes on the doppler image with prolonged augmentation (valsalva). Should a patient have a sudden onset RIGHT sided varicocele, one must also consider retroperitoneal pathology, especially renal cell cancer.

Treatment Options:

1) Open Surgery -  This is performed on an outpatient basis under general or local anesthesia via various approaches [transinguinal vs. retroperitoneal vs. infrainguinal/infrapubic].  The transinguinal approach is the most commonly used.  Surgical repair results in fertility in about half of men, with the best results in those that have a pre-op sperm count of >10 million.

2) Laparoscopic surgery – this is not usually performed as it poses increased risk while offering little advantage over that of open repair.

3)  Percutaneous embolization – this procedure is rarely used due to the length of the procedure and risks involved. It is commonly reserved for recurrent varicoceles.

For self-treatment options for minor symptoms, it is recommended to take OTC pain meds such as acetaminophen and/or to wear an athletic supporter to assist in relieving gravitational pain. If left untreated, a varicocele may continue to cause damage to the testicle resulting in atrophy and irreparable infertility. Recurrence rates are approximately 10%.

For further reading, plase see:

1) Harrisons Textbook of Internal Medicine

2) www.mayoclinic.com

3) www.keepingyouwell.com

4) www.climedin.com

5) Emedicine.com