Varicocoele Flashcards
Define varicocoele
Abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis and spermatic cord
Grades of varicocoele
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.
Aetiology of varicocele
Abnormal dilatation of the pampiniform plexus (drains the testes and spermatic cord)
Incompetent valves in the testicular veins
90% occur on the left due to the angle of insertion of the vein into the renal vein (more perpendicular) + higher pressure
Pampiniform plexus → testicular veins → (right → inferior vena cava) (Left → renal vein → IVC)
May be caused by a retroperitoneal or abdominal compressive mass
Associated with abnormal gonadotrophin levels, impaired spermatogenesis, histological changes to sperm, and infertility
Risk factors for varicocoele
Somatometric parameters (tall + heavier - low BMI)
Family history (esp. first degree, siblings)
Why are varicocoeles more common in the left
Left testicular vein drains into renal vein at a 90-degree angle
Left testicular vein is longer than right
Left testicular vein often lacks a terminal valve to prevent back flow
Left testicular vein can be compressed by renal and bowel pathology
Symptoms and signs of varicoele
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
Valsalva manoeuvre → engorges veins further
Investigations for varicocele
Clinical diagnosis
FSH: may be elevated due to testicular dysfunction
Testosterone: may be low due to impaired steroidogenesis
Scortal US with colour flow doppler: enlarge veins + abnormal reflux of blood
Semen analysis: if struggling with fertility
CT/MRI/US: exclude causative mass
Who needs to be referred to a urologist
Refer urgently to a urologist if:
- A varicocele appears suddenly and is painful.
- The varicocele does not drain when lying down.
Management for varicocoele
Grade I: no treatment is necessary
Grade II or III asymptomatic: consider observing with semen analysis every 1–2 years if clinically appropriate
Grade II or III symptomatic: refer to a urologist for possible surgery
Conservative:
- Reassure the patient that they are very common
- Scrotal support - jockstrap or tighter pants
surgery:
- Radiological embolisation
- Sclerotherapt
- Surgical ligation (Palomo op, usually in the groin)
Complications of varicocoele
Pain
Failure of ipsilateral testicular growth → hypogonadism
Fertility problems
Prognosis for varicocele
Most varicoceles are asymptomatic, do not affect fertility, and do not require treatment.
Varicocelectomy is overall associated with:
- Reduced pain.
- Improved semen parameters — although data regarding whether this translates to improved pregnancy rates are highly conflicting.
What is the association of varicocoele with malignancy
L sided is associated with renal cell cancer
Sudden appearance in middle-age of a varicocele should lead one to have low threshold to exclude renal cell carcinoma by further investigations.
