varicocele; cirsocele; pampinocele

Etiology

• left-sided varicoceles are a classic presenting symptom of renal-cell carcinoma & other intra-abdominal tumors

Epidemiology

• incidence in infertile men is 20-30%

Pathology

• dilation of the veins of the spermatic cord secondary to incompetent valves in the internal spermatic vein
• impaired drainage of blood into the spermatic cord veins occurs when the patient assumes an upright position
• varicoceles can occur by thrombosis of the testicular vein
• varicoceles can develop in the left hemiscrotum because of blockage & pressure from either tumor thrombosis in the left renal vein or external compression by a mass*

* In most patients, the left testicular vein drains into the left renal vein, whereas the right testicular vein drains directly into the inferior vena cava

* consider inferior vena cava obstruction with right-sided varicocele (compression from a tumor mass)

Clinical manifestations

• asymptomatic to dull ache with scrotal fullness
• generally left-sided (90%)
• "bag of worms" consistency with palpation of scrotum
• generally diminishes in supine position
• worsens with standing & Valsalva
• negative Prehn's sign, no fever
• chronic disorder
• no transillumination

Laboratory

• semen analysis
  • decreased sperm count & motility may be noted
  • abnormal sperm morphology may be noted
• serum chemistries
  • testosterone is normal
  • gonadotropins LH & FSH are normal

Radiology

• ultrasonography
• CT of abdomen & pelvis if acute onset of varicocele that does not diminish in supine position (inferior vena cava obstruction)

Management

• no treatment in asymptomatic young male
• NSAIDs & scrotal support
• if acute onset in older male, consider left renal vein thrombosis from retroperitoneal neoplasm
• varicocelectomy if infertility is a problem

More general terms

• varicose vein (varix)