Varicocele

Question 1

A … refers to dilated veins within the pampiniform plexus.

Answer 1

A varicocele refers to dilated veins within the pampiniform plexus.

Question 2

The pampiniform plexus is a network of veins found in the spermatic cord that drains the testes and epididymis. Varicoceles occur most commonly in adolescent boys and may affect up to 15% of men. The vast majority (around 90%) occur on the … side.

Answer 2

The pampiniform plexus is a network of veins found in the spermatic cord that drains the testes and epididymis. Varicoceles occur most commonly in adolescent boys and may affect up to 15% of men. The vast majority (around 90%) occur on the left side.

Question 3

It is strongly associated with infertility and as such … are seen in around 40% of men presenting with infertility.

Answer 3

It is strongly associated with infertility and as such varicoceles are seen in around 40% of men presenting with infertility.

Question 4

Varicoceles occur due to dilation of the pampiniform plexus in the ….

Answer 4

Varicoceles occur due to dilation of the pampiniform plexus in the scrotum.

Question 5

Aetiology of varicocele

Answer 5

The pampiniform plexus is a network of veins found in the spermatic cord that drains the testes and epididymis. They drain proximally via the gonadal veins (also termed testicular veins in men).

Anything that leads to increased pressure within these veins may cause a varicocele. This may be caused by incompetent or absent valves. Rarely varicoceles can herald a compressive mass or vascular spread of a malignancy. This is classically described in renal cell carcinoma with spread into the left renal vein.

Question 6

Where do the majority of varicoceles occur?

Answer 6

The majority occur on the left side (around 90%) due to the asymmetrical anatomy (though it should be noted variant anatomy is common). The left gonadal vein is longer and joins the left renal vein at a right angle and as such is more likely to have raised pressures. The right gonadal vein drains more obliquely, directly into the IVC.

Question 7

Varicoceles may be a sign of …

Answer 7

Malignancy

Varicoceles may be a sign of renal cancer (or other intra-abdominal cancers/masses). The majority of varicoceles occur on the left side as the left gonadal vein tends to drain at a sharp angle into the left renal vein and is longer than the right draining into the IVC. The vast majority of varicoceles will not indicate cancer, however, tumours that compress venous return (classically left side, but right side may also be affected) can be a cause.

Question 8

Clinical features of varicoceles?

Answer 8

Varicoceles are frequently asymptomatic apart from the palpable veins.

Question 9

What is the most common symptom in a varicocele?

Answer 9

The most common symptom is painless scrotal swelling / palpable veins. This is classically described as a ‘bag of worms’. It may reduce on lying down and be exacerbated by a Valsalva manoeuvre.

Signs of testicular atrophy can sometimes be seen on the affected side. Some patients develop symptoms of discomfort, pain or a dragging sensation.

Question 10

Diagnosing varicocele

Answer 10

Varicoceles are normally a clinical diagnosis.

Question 11

Testicular exam will normally demonstrate what in a varicocele?

Answer 11

Testicular examination will normally demonstrate dilated veins - classically described as a bag of worms. The examination is conducted both standing and lying down and may involve dynamic manoeuvres (e.g Valsalva manoeuvre - forced expiration against a closed glottis). The size of each testicle should be evaluated.

Doppler USS may be used in cases of diagnostic uncertainty. Fertility assessments may be completed. Semen analysis can be sent alongside FSH and testosterone levels.

Question 12

Grading of varicoceles

Answer 12

Sub-clinical: no clinical abnormality, only detected by Doppler ultrasound.

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

Grade II (moderate): palpable without Valsalva manoeuvre.

Grade III (large): varicocele is visible through the scrotal skin, easily palpable.

Question 13

Two key related complications of varicoceles?

Answer 13

The two key (related) complications of varicoceles are testicular atrophy and infertility.

Question 14

Testicular atrophy in varicocele

Answer 14

Varicoceles may lead to testicular damage and atrophy. Up to 25% of boys with Grade II/III varicoceles develop testicular growth arrest. This is a key indication for surgery - recovery of growth is seen in around 50-80% of cases. Patients with evidence of growth arrest should be referred to urology.

Question 15

Infertility/subfertility in varicoceles

Answer 15

Varicoceles may effect efficacy and function of sperm. The exact pathophysiology is unclear but may involve impairment of the normal countercurrent mechanism leading to raised intra-scrotal temperatures. Vascular congestion within the testicle may also be responsible.

Surgical management to improve fertility is an area of controversy. Currently, NICE CG 156 advises against varicocele surgery for infertility as it does not appear to improve pregnancy rates. However, NICE CKS on varicoceles does recommend referral to urology in men with abnormal semen parameters and grade II/III varicocele for consideration of surgery.

Question 16

NICE outlines a number of specific instances in which to refer patients.
Refer any patient who’s varicocele becomes symptomatic.
When is urgent referral advised? (3)

Answer 16

Urgent referral is advised if:

It appears suddenly and is painful
Does not drain when lying down
Solitary right-sided varicocele

Question 17

Adolescents may be referred if:

Answer 17

Reduced testicular volume

Patient or parental concern

Question 18

Although left varicoceles usually occur physiologically, when one develops acutely in a man with no history of previous genital trauma, this raises suspicion of …

Answer 18

Although left varicoceles usually occur physiologically, when one develops acutely in a man with no history of previous genital trauma, this raises suspicion of a retroperitoneal mass (usually renal cancer).

Question 19

If the scrotal swelling is of uncertain origin, the patient should be referred to urology. Men with infertility may also be referred, particularly if Grade II/III disease with abnormal semen parameters.

Answer 19

If the scrotal swelling is of uncertain origin, the patient should be referred to urology. Men with infertility may also be referred, particularly if Grade II/III disease with abnormal semen parameters.

Question 20

Currently, when needed, surgical/endovascular techniques are the only treatment options of varicocele

Answer 20

Grade I and subclinical disease rarely need treatment. Surgery tends to be considered in symptomatic disease and testicular growth arrest/atrophy. It may be considered in infertility but this is an area of controversy (see above).

Question 21

Observation of varicocele in adolescents

Answer 21

NICE CKS advises observing adolescents Grade II and III varicoceles and symmetrical testicles with yearly examinations. Refer those who become symptomatic or develop asymmetry.

Question 22

Surgical approach to a varicocele (4)

When intervention is indicated surgery is the most common management. There are a multitude of approaches:

Answer 22

Inguinal / subinguinal approach
Retroperitoneal high ligation
Microsurgical inguinal
Laparoscopy

Question 23

Recurrence rates of varicocele

Answer 23

​​​​Recurrence rates vary but sit around 5-10%. Microsurgical techniques appear to have the advantage of very low recurrence and risk of arterial and lymphatic injury.

Question 24

Endovascular - varicocele management

Less commonly endovascular techniques may be used. They generally avoid a general anaesthetic, though do expose the patient to radiation. Options include: (3)

Answer 24

Antegrade sclerotherapy
Retrograde sclerotherapy
Retrograde embolisation

Question 25

Which veins are dilated in a varicocele?

Answer 25

A varicocele refers to dilated veins within the pampiniform plexus.

Question 26

The pampiniform plexus is important in the drainage of blood via the … veins (also termed testicular veins in men). Anything that leads to increased pressure may cause varicoceles.

Answer 26

The pampiniform plexus is important in the drainage of blood via the gonadal veins (also termed testicular veins in men). Anything that leads to increased pressure may cause varicoceles.

Question 27

Increased pressure may be caused by incompetent or absent valves. Rarely varicoceles can herald a compressive mass or vascular spread of a malignancy. This is classically described in renal cell carcinoma with spread into the …

Answer 27

Increased pressure may be caused by incompetent or absent valves. Rarely varicoceles can herald a compressive mass or vascular spread of a malignancy. This is classically described in renal cell carcinoma with spread into the left renal vein.

Question 28

The majority of varicoceles occur on the left side (around 90%) due to the asymmetrical anatomy (note variant anatomy is common). The left gonadal vein is longer and joins the left renal vein at a right angle. The right gonadal vein drains more obliquely, directly into the …

Answer 28

The majority of varicoceles occur on the left side (around 90%) due to the asymmetrical anatomy (note variant anatomy is common). The left gonadal vein is longer and joins the left renal vein at a right angle. The right gonadal vein drains more obliquely, directly into the IVC.

Question 29

A 17 year old boy is seen in the urology clinic with a varicocele
Which of the following would be the most concerning in this case?
A Pain
B Small, asymmetrical testis
C Large varicocele
D Left-sided varicocele
E Non-tender

Answer 29

B Small, asymmetrical testis (correct answer)

The two key complications of varicoceles are testicular atrophy and infertility.

The most concerning feature would be a small, asymmetrical testis, which is suggestive of testicular atrophy.

Varicoceles may lead to testicular damage and atrophy. Up to 25% of boys with Grade II/III varicocele may develop testicular growth arrest. This is a key indication for surgery, which leads to recovery of growth in around 50-80% of cases. Patients with evidence of growth arrest should be referred to urology.

Question 30

A 24 year old male is seen by the GP with a testicular lump. He first noticed the lump a few weeks ago and after finding out more information on the internet, he is extremely concerned about cancer. He is otherwise well with no past medical history. He works in finance and is a non-smoker. On examination, there is no major asymmetry. On palpation of the left testis there is evidence of a soft, non-tender mass superiorly to the testis. It is easily felt when asking the patient to perform a Valsalva manoeuvre. It feels like a small bag of worms. The testis feels normal in shape and consistency.

What is the most likely diagnosis?

Answer 30

The presence of a non-tender mass, superior to the testis that feels like a ‘bag of worms’ is classic of a varicocele.

Question 31

Varicoceles

Answer 31

Varicoceles are usually asymptomatic. They may be noticed on self-examination or as part of a work-up for infertility. A small proportion (2-10%) may get pain associated with the varicocele. This is typically described as dull and aching. The diagnosis of varicocele is usually based on examination alone, but may be confirmed with doppler ultrasound.

A hydrocele refers to a collection of fluid within the scrotum between the layers of the tunica vaginalis. They may be communicating due to a patent processus vaginalis or non-communicating. Clinically, they vary in size, typically sit anterior to the testis and feel like a water-filled balloon. It may be difficult to feel the testis and they are usually non-tender.