Varicocele

Overview

Introduction

A 13-year-old boy presents to the urgent care clinic and reports pain in his scrotal area. He denies any rashes or inciting trauma. The pain is dull and does not radiate anywhere. On physical exam, there is a “bag of worms” on palpation of the left scrotum. The scrotum does not transilluminate with light.

Introduction

Clinical definition
- varicose veins in the scrotum
Epidemiology
- incidence
  - 15% in adult men
  - 8-20% in adolescent boys
  - most common cause of scrotal enlargement in adult males
- demographics
  - around puberty in adolescents
- location
  - most often on left side
    - due to increased resistance from left gonadal vein draining into left renal vein
Etiology
- primary varicocele
  - venous reflux
- secondary varicocele
  - renal cell carcinoma causing compression to the veins
Pathogenesis
increased venous pressure causing dilated veins in the pampiniform plexus

Presentation

Symptoms
- primary symptoms
  - dull ache in scrotum
  - feeling of heaviness in scrotum
  - may be asymptomatic
  - infertility
  - atrophy
Physical exam
- standing or valsalva maneuver
  - distension on inspection
  - “bag of worms” on palpation
- illumination test with light
scrotum does not transilluminate

Imaging

Differential

Treatment

Conservative
- monitor with annual exams
  - indications
    - asymptomatic patients
    - no testicular hypotrophy
Operative
- surgical ligation or embolization
  - indications
    - pain
    - infertility
delayed growth of testes

Complications