Varicocoele

Varicose dilatation of the veins draining the testis

Pathophysiology

• Pampiniform plexus is formed by veins draining testis and epididymis. Veins gradually join together as they traverse the inguinal canal. At the inguinal ring, there are only one or two testicular veins, which then pass upwards through the retroperitoneum. Left vein to left renal vein, while right vein goes to IVC. The testicular veins usually have valves near their terminations, but these are sometimes absent. Alternative venous return from the testis is through the cremasteric veins, which drain mainly into the inferior epigastric veins.
• 90% left-sided
• Incidence about 20% of all men
• Unusual in boys - typically develop during late childhood and adolescence
• Mostly the affected veins are from the pampiniform plexus
• Usual cause is absent or incompetent valves in proximal testicular vein

Aetiology

• Idiopathic - most common
• Obstruction of left testicular vein
  • Renal tumour
  • Nephrectomy

History

• Mostly asymptomatic
• Symptomatic varicocoeles tend to present in adolescence or early adulthood
• Annoying dragging discomfort that is worse on standing at the end of the day

Examination

• While standing, scrotum on affected side hangs lower
• Feels like bag of worms
• May be a cough impulse
• Check whether it decompresses while supine - if not, likely secondary to external obstruction
• Check testis
• Can be associated with atrophy in chronic cases

Investigation

• Ultrasound will diagnose if in doubt
• Check draining veins for external obstruction

Grading:

• Grade I: impalpable
• Grade II: palpable
• Grade III: visible

Impact on fertility

• Controversial
• Little evidence that varicocoelectomy improves semen quality or rate of conception

Surgery

• Indications
  • Significant discomfort
  • Men <21yo with testicular hypotrophy or abnormal semen parameters
  • Men >21yo with abnormal semen parameters
• Procedures
  • Percutaneous embolisation of gonadal veins
    • Recurs in 20%
  • Ligation of testicular veins
    • Can still recur
    • Open - cutdown at external ring
    • Laparoscopic - ligate just proximal to internal ring