Varicocele

Question 1

Definition

Answer 1

Dilation of veins of the pampniform plexus of the spermatic cord

Question 2

Predominant location

Answer 2

Left hemi-scrotum

Question 3

Pathophysiology

Answer 3

1. Left spermatic vein enters the left renal vein at a perpendicular angle and the intravascular pressure in the left renal vein > right (bc compressed between the aorta and SMA)
2. Increased pressure in the left spermatic vein which can dilate leading to incompetence of the valve leaflets –> retrograde flow of blood toward testis in the erect position

Question 4

Clinical Presentation

Answer 4

Asymptomatic

Symptomatic
1. Dull aching
2. Left scrotal pain; noticable when standing and relieved by lying down
3. Testicular atrophy
4. Decreased fertility
5. When palpating on standing,
a. Mass separate from testes, can get above it
b. Feels like a bag of worms
c. Compressible mass above or surrounding the testes
d. Not transilluminable

Question 5

Classification

Answer 5

1. Subclinical: Vein > 3mm on U/S, Doppler reflux on Valsalva maneuveuer
2. Grade 1: Palpable with Valsalva only
3. Grade 2: Palpable at rest
4. Grade 3: Visible Easily

Question 6

Management

Answer 6

1. Conservative
   - Scrotal Support and NSAIDs
2. Surgical
   - Transfemoral Angiographic Embolization with coil or sclerosant
   - Surgical Ligation: Excise the surrounding dilated veins via high retroperitoneum, inguinal or laparoscopic approach