Varicocele

Varicocele is abnormal dilatation of the pampiniform venous plexus.

It occurs predominantly on the left because the left gonadal vein drains into the left renal vein.

Varicocele can impair testicular function through:

• Increased scrotal temperature
• Oxidative stress
• Venous reflux
• Altered testicular microcirculation

Clinical grading

Grade I

Palpable only during Valsalva.

Grade II

Palpable at rest but not visibly obvious.

Grade III

Visible through scrotal skin.

Subclinical varicocele is detectable only by imaging and generally does not warrant treatment for infertility.

Presentation includes:

• Infertility
• Dull scrotal ache
• Scrotal heaviness
• Visible bag of worms appearance
• Adolescent testicular growth discrepancy

A new isolated right sided varicocele, particularly if nonreducible or of sudden onset, should prompt consideration of retroperitoneal or venous obstruction.

Physical examination is performed standing and with Valsalva.

Scrotal Doppler ultrasound is useful when:

• Examination uncertain
• Recurrent varicocele
• Adolescent testicular volume assessment
• Another scrotal pathology possible

For infertility, obtain semen analysis before deciding treatment.

Observation is appropriate for an asymptomatic man with:

• Normal testicular size
• Normal fertility
• No pain

Treat when there is:

• Infertility with clinically palpable varicocele and abnormal semen parameters
• Persistent pain despite conservative measures
• Significant adolescent testicular growth arrest

A persistent testicular volume difference around 20% is commonly used as an important adolescent treatment threshold.

Microsurgical varicocelectomy

Microsurgical subinguinal or inguinal ligation provides excellent control with low recurrence and hydrocele risk.

Preserve:

• Testicular artery
• Lymphatics
• Vas deferens

Ligate abnormal internal spermatic veins.

Embolisation

Percutaneous gonadal vein embolisation is an alternative, particularly:

• After recurrent surgical varicocele
• When avoiding an incision is preferred

Technical failure can occur if venous anatomy prevents catheterisation.