Definition
A.Varicocele is engorgement of the internal spermatic veins above the testes. This vascular abnormality is a cause of decreased testicular function. Some varicoceles are easy to identify and may be surgically corrected. The presence of a varicocele does not mean that surgical correction is a necessity.
Incidence
A.Varicocele may occur in 15% to 20% of normal males; 80% to 90% of cases occur on the left side. Up to 35% to 40% of men with a palpable left-sided varicocele may actually have bilateral varicoceles that are identified upon physical examination.
B.Right-sided varicocele is uncommon and can indicate retroperitoneal malignancy. Varicocele is the leading known cause of male infertility (40%). Decreased sperm counts, infertility, and testicular atrophy occur in 65% to 75% of varicocele cases. There is no correlation between size of the varicocele and the degree of infertility.
Pathogenesis
A.The exact pathophysiologic mechanisms for varicoceles are not fully identified. Varicoceles may be caused by valvular incompetence or elevated hydrostatic pressure in the spermatic veins. Testicular temperature elevation also appears to play a role in varicocele-induced dysfunction. New varicoceles in older men may be secondary to renal tumors.
Predisposing Factors
A.Varicoceles generally manifest at the time of puberty.
Common Complaints
A.Asymptomatic.
B.Infertility.
C.Pain or discomfort in the scrotum.
Other Signs and Symptoms
A.Pain or aching and heaviness in the scrotum.
B.Feels like worms
; scrotum may have bluish discoloration.
Subjective Data
A.Note the onset, course, and duration of symptoms. When was the varicocele first noted?
B.Has the scrotum enlarged? If there is enlargement, over what time span? Does it collapse with lying or sitting down?
C.Is there any pain or discomfort?
D.Has there been any history of infertility?
Physical Examination
A.Check vital signs, temperature as indicated.
B.Inspect:
1.The examination should be done when the patient is lying or standing in a warm room. Warm temperature promotes relaxation of the scrotum.
2.Examine the general appearance of the penis; note scrotal size, shape, and rugae. Varicocele tends to collapse with the patient sitting or supine.
3.Transilluminate the scrotum to visualize the varicocele.
4.Large varicocele can easily be identified by inspection.
C.Palpate:
1.Palpate each side of the scrotum for testicular size, presence of varicocele (Valsalva maneuver performed while the patient stands helps to reveal a small varicocele), and absence of vas deferens:
a.A moderate-size varicocele can be identified by palpation without having the patient perform the Valsalva maneuver.
2.Palpate the spermatic cord between the thumb and forefingers while the patient performs a Valsalva maneuver:
a.A small varicocele is identified only when the patient bears down, increasing the intraabdominal pressure.
b.Varicocele should significantly diminish in size when the patient assumes the supine position.
3.Evaluate whether the varicocele can be reduced while the patient is supine.
4.Palpate the abdomen for hernias, masses, and tenderness.
5.Rectal exam: Palpate the prostate and seminal vesicles for tenderness and other signs of infection.
D.Auscultate: Listen over the scrotum to assess bowel sounds to rule out hernia.
Diagnostic Tests
A.Scrotal ultrasound with a high-resolution color-flow Doppler is the diagnostic method of choice when clinical exams are equivocal, but are not indicated for standard evaluation.
B.Semen analysis times two, if indicated.
C.CT to evaluate retroperitoneal pathology (e.g., renal cell carcinoma) for:
1.Sudden onset of varicocele.
2.Single right-sided varicocele.
3.Any varicocele that is not reducible in the supine position.
Differential Diagnosis
A.Varicocele classifications:
1.Grade I (small): Palpable only on Valsalva maneuver, which increases intraabdominal pressure and therefore impedes drainage and increases the varicocele size.
2.Grade II (moderate): Palpable when standing and bearing down (Valsalva maneuver).
3.Grade III (large): Visible on inspection alone.
4.Subclinical: Not palpable; vein larger than 3 mm on ultrasound; Doppler reflux on Valsalva maneuver.
B.Hernia.
C.Epididymitis.
D.Hydrocele.
E.Testicular tumor: Consider retroperitoneal tumor, especially if presenting symptoms have a sudden onset.
Plan
A.Urologic consultation for diagnosis and possible surgery. Surgery should be considered when all of the following conditions are met:
1.Palpable varicocele found upon physical examination.
2.Couple with known infertility.
3.Female with normal fertility or potential treatable cause of infertility.
4.Male partner with abnormal semen parameters or abnormal results from sperm function tests.
B.
See Section III: Patient Teaching Guide for Testicular Self-Examination
.
1.If discomfort is present, an athletic supporter should be tried.
2.If surgery is not indicated, no interventions are needed.
C.Pharmaceutical therapy: None is recommended.
Follow-Up
A.After surgery, no follow-up is necessary if the patient is taught scrotal self-examination.
B.If no surgery is performed, the patient should be taught self-examination and instructed to return for pain or change in size and shape.
C.Adolescents with varicoceles should be followed with annual objective measurements of testis
size and/or semen analyses in order to detect the earliest sign of varicocele-related testicular injury.
Consultation/Referral
A.Refer the patient to a urologist for surgical evaluation. Varicocelectomy is recommended in cases of pain and infertility, and it may be offered in the preadolescent to ensure proper testicular development.
Individual Considerations
A.Adults:
1.New onset varicocele in older male may indicate a renal tumor.