Varicocele

Question 1

Define Varicocele

Answer 1

Abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis and spermatic cord

Question 2

What are the grades of varicocele

Answer 2

Grade I (small): varicocele palpable only with Valsalva manoeuvre.

Grade II (moderate): varicocele palpable without Valsalva manoeuvre.

Grade III (large): varicocele visible through the scrotal skin.

Sub-clinical: varicocele detected only by Doppler ultrasound.

Question 3

Aetiology of Varicoceles

Answer 3

The pampiniform plexus eventually form the 2 testicular veins within the abdomen
On the right, the testicular vein joins the inferior vena cava. On the left, the testicular vein joins the left renal vein (which then goes on to join the inferior vena cava itself).

If the valves in the testicular veins that normally prevent backflow are defective, blood will reflux back into the pampiniform plexus.
Up to 90% of varicoceles occur on the left. This is partly because of the angle of insertion of the left testicular vein into the left renal vein + higher pressure

May be caused by a retroperitoneal or abdominal compressive mass
Associated with abnormal gonadotrophin levels, impaired spermatogenesis, histological changes to sperm, and infertility

Question 4

Symptoms of Varicocele

Answer 4

Scrotal mass (Painless | Described as "a bag of worms" | Often on the left | More prominent when standing and disappears when supine)
‘heavy’ sensation in their scrotum
Small testicle
Infertility 
Scrotal or groin pain

Question 5

Signs of Varicoceles on examination

Answer 5

Scrotal mass (Painless | Described as "a bag of worms" | Often on the left | More prominent when standing and disappears when supine)
Small testicle

Question 6

Investigations for Varicoceles

Answer 6

Scrotal USS with colour flow Doppler: presence of varicocele (enlarged veins + reflux of blood with valsalva)

Semen analysis: ?infertility

Serum FSH: ?testicular dysfunction -> elevated
Serum testosterone: ?impaired steroidogenesis
DNA fragmentation index: elevated

CT/MRI abdomen/Pelvis: exclude mass
Retroperitoneal USS: exclude mass
Kidney USS: exclude cancer