Varicocele
NICE CKS Varicocele. Last revised: Jan 2023.
Also see the Scrotal Lump and Swelling article on how to differentiate between the differential diagnoses.
Definition
A varicocele is a scrotal swelling consisting of a collection of dilated veins of the pampiniform plexus in the spermatic cord
Aetiology
Most cases are idiopathic (due to incompetent / absent valves in the testicular vein
- ~90% affects the left testicles (and the remaining 10% are bilateral), because the left testicular vein drains vertically into the left renal vein, at a right angle. The increased pressure in the vertical column of blood can lead to dilatation of the pampiniform plexus.
- The left testicular vein is also longer, and the right testicular vein drains at an oblique angle into the inferior vena cava.
Secondary causes (due to obstruction / compression of venous drainage):
- Renal cell carcinoma (due to tumour thrombus or compression of the renal / testicular vein)
- Renal vein thrombosis
- Nutcracker syndrome (compression of the left renal vein between the superior mesenteric artery and the aorta)
- Abdominal / pelvic masses (e.g. abdominal tumours, para-aortic lymphadenopathy)
Secondary varicoceles are more often right-sided, as there is no normal anatomical predisposition to varicocele formation on the right.
Clinical Features
Primary varicoceles become apparent during adolescence, coincident with accelerated body growth and increased blood flow to the testes
Typical features:
- Painless scrotal swelling
- Scrotal pain / dragging sensation / heavy sensation is uncommon, only in <3% patients
- ‘Bag of worms’ appearance (from dilation and tortuosity of the veins) within the spermatic cord above the testis
- Small testis / asymmetrical testes
Examine the patient in supine and standing positions:
- The varicocele is more obvious / increase in size on standing and while performing the Valsalva manoeuvre
- The varicocele usually disappears when lying down
- -ve Transillumination test
Primary varicoceles are usually left-sided (~90%), and the remaining 10% are bilateral.
Unilateral right-sided varicoceles are more likely to be secondary.
Complications
In adolescents, the main complication is impaired ipsilateral testicular growth and development → hypogonadism
In adults, the main complication is fertility problems
- ~20% of males with varicocele will have fertility problems
- Increased scrotal temperature, hypoxia, and reflux of toxic metabolites leading to testicular damage are possible underlying mechanisms
Investigation and Diagnosis
Clinical diagnosis (based on clinical features)
- If there is diagnostic uncertainty → ultrasound with colour flow Doppler
- Ultrasound findings: dilated pampiniform plexus (≥3mm), retrograde blood flow in the testicular vein
Further testing:
- Adults: consider testing for testicular function with semen analysis, serum FSH, and serum testosterone levels
- Abnormal sperm production with an elevated FSH is consistent with impaired spermatogenesis
- Adolescents: check for testicular asymmetry (which indicates impaired testicular growth)
Management
Management depends on age:
- In adolescents, management aims to protect future testicular development
- In adults, management aims to improve symptoms or fertility
Adolescents
| Varicocele grade | Description | Management |
|---|---|---|
| Sub-clinical | Detected only by Doppler ultrasound | No treatment necessary – provide advice and reassurance |
| Grade I (small) | Palpable only with Valsalva manoeuvre | |
| Grade II (moderate) | Palpable without Valsalva manoeuvre | If there is testicular growth arrest (indicated by asymmetrical testes) → refer to urology for possible surgery (varicocelectomy)
If there are symmetrical tests → annual examination (surgery not necessary) |
| Grade III (large) | Visible through the scrotal skin |
Adults
| Varicocele grade | Description | Management |
|---|---|---|
| Sub-clinical | Detected only by Doppler ultrasound | No treatment necessary – offer semen analysis if fertility is a concern |
| Grade I (small) | Palpable only with Valsalva manoeuvre | |
| Grade II (moderate) | Palpable without Valsalva manoeuvre | Refer to urology for possible surgery (varicocelectomy) if:
Otherwise, consider observing with semen analysis every 1-2 years |
| Grade III (large) | Visible through the scrotal skin |