History

Fact Explanation
A patient with a varicocele is usually asymptomatic A varicocele is condition associated with dilatation of the pampiniform venous plexus (veins of the testes and epididymis) and the internal spermatic vein[3].
Infertility[1][2][3] This is the most common presentation The exact mechanism which causes infertility/ effect on spermatogenesis was not identified. It is assumed that high temperature inside the testicular vein due to the collection of blood can affect spermatogenesis. Another possibility is DNA damage of the sperm heads due to oxidative stress associated with pooling of blood. Though varicocele is thought to increase the chances of infertility, most men with a varicocele are not infertile. This condition can be seen in, 15-20% among the entire male population and among 40% of infertile males. Majority of males with varicocele have ipsilateral testicular atrophy[3].
Scrotal pain[9] or heaviness[4][5] Though a varicocele is often asymptomatic, it may cause pain in 10% and it can vary from dull discomfort (feeling of heaviness) to a sharp pain. this pain/ discomfort is usually increased on standing /with physical exertion for a long period and when no support available for the scrotum. Also it may worsen over the course of the day and relieved when lying supine.
Abag of worms feeling in the scrotum Due to the A varicocele is condition associated with dilatation of the pampiniform venous plexus (veins of the testes and epididymis) and the internal spermatic vein[3] patient may see these veins as a bag of worms in the scrotum.
Features of renal cell carcinoma[6] such as painless haematuria, loss of weight, loss of appetite, easy fatigability and lethargy The left testicular vein drains first into the left renal vein and then to inferior vena cava (IVC) while right testicular vein drains directly into IVC just below the renal vein. A renal cell carcinoma can block the renal vein due to compression by the growth of the carcinoma or due to the obstruction by the cancer cells. This leads to occurrence of varicocele on the left side.
Cushingoid features or virilization Adrenocortical tumors[8] can present with varicocele due to vasoconstriction with catecholamines or mechanical obstruction. Adrenocortical tumors also give rise to Cushing's features, virilization and features of hyper aldosteronism.
References
  1. FREIHA F, MROUEH A. Varicocele and Infertility in Men West J Med [online] 1976 Dec, 125(6):431-433 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1237390
  2. REDMON JB, CAREY P, PRYOR JL. Varicocele--the most common cause of male factor infertility? Hum Reprod Update [online] 2002 Jan-Feb, 8(1):53-8 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11866240
  3. JAROW JP. Effects of varicocele on male fertility. Hum Reprod Update [online] 2001 Jan-Feb, 7(1):59-64 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11212076
  4. SHRIDHARANI A, LOCKWOOD G, SANDLOW J. Varicocelectomy in the treatment of testicular pain: a review. Curr Opin Urol [online] 2012 Nov, 22(6):499-506 [viewed 08 August 2014] Available from: doi:10.1097/MOU.0b013e328358f69f
  5. ARMAğAN A, ERGüN O, BAş E, OKSAY T, KOşAR A. Long-term effects of microsurgical varicocelectomy on pain and sperm parameters in clinical varicocele patients with scrotal pain complaints. Andrologia [online] 2012 May:611-4 [viewed 08 August 2014] Available from: doi:10.1111/j.1439-0272.2011.01238.x
  6. COHEN HT, MCGOVERN FJ. Renal-cell carcinoma. N Engl J Med [online] 2005 Dec 8, 353(23):2477-90 [viewed 08 August 2014] Available from: doi:10.1056/NEJMra043172
  7. CHOW WH, DONG LM, DEVESA SS. Epidemiology and risk factors for kidney cancer Nat Rev Urol [online] 2010 May, 7(5):245-257 [viewed 08 August 2014] Available from: doi:10.1038/nrurol.2010.46
  8. CHEUNGPASITPORN W, HORNE JM, HOWARTH CB. Adrenocortical carcinoma presenting as varicocele and renal vein thrombosis: a case report J Med Case Reports [online] :337 [viewed 08 August 2014] Available from: doi:10.1186/1752-1947-5-337
  9. PADUCH DA, SKOOG SJ. Current Management of Adolescent Varicocele Rev Urol [online] 2001, 3(3):120-133 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476052

Examination

Fact Explanation
Fullness of the scrotum which is more prominent on standing and less prominent on lying down. Usually the affected side will hang lower than the other hemi-scrotum. Dilated pampiniform venous plexus[5] will be more prominent showing fullness of the scrotum. When lying down, the blood from the veins drains away and the varicocele may disappear or reduce in size. On standing[1], gravity will cause the blood to pool again and the varicocele reappears/ and become more prominent. Based on the clinical findings, varicocele can be graded as follows: Large (grade III) is easily visible, Medium (grade II) is palpable at rest, Small (Grade 1) is only palpable during Valsalva maneuver. [9][10]
Bag of worms feeling on palpation[5] Dilated pampiniform venous plexus will be palpable to the examiner as a bag of worms.
Compressibility[12] As this lesion consists of blood filled veins, it can be compressed with the pressure but as soon as compression is removed refilling occurs.
Does not transilluminate[11] This is not transilluminable [8] as it contains blood.
Cough impulse may be present. Cough impulse will be present as the lesion becomes prominent with increased intra-abdominal pressure during coughing.
Testis can be palpated separately from the lesion and size will be smaller[7] Pampiniform venous plexus is situated outside the testis, so the testis can be palpated separately. Alteration in thermoregulation, disruption of the blood supply to the testis and blood pooling causing exposure to toxins in blood for a long period may leads to shrinkage of the affected testicle and subsequent atrophy[6].
Evidence of renal cell carcinoma[4]: pallor, wasting, scalp lumps, ballotable renal mass Renal cell carcinoma can associated with a varicocele.
Measurement of testicular volume with Prader and Rochester orchidometers [13][14] This is useful in measuring the testicular volume as testicular atrophy is associated with a varicocele.
References
  1. JAROW JP. Effects of varicocele on male fertility. Hum Reprod Update [online] 2001 Jan-Feb, 7(1):59-64 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11212076
  2. GAT Y, BACHAR GN, ZUKERMAN Z, BELENKY A, GORNISH M. Varicocele: a bilateral disease. Fertil Steril [online] 2004 Feb, 81(2):424-9 [viewed 08 August 2014] Available from: doi:10.1016/j.fertnstert.2003.08.010
  3. CHEUNGPASITPORN W, HORNE JM, HOWARTH CB. Adrenocortical carcinoma presenting as varicocele and renal vein thrombosis: a case report J Med Case Reports [online] :337 [viewed 08 August 2014] Available from:
  4. COHEN HT, MCGOVERN FJ. Renal-cell carcinoma. N Engl J Med [online] 2005 Dec 8, 353(23):2477-90 [viewed 08 August 2014] Available from: doi:10.1056/NEJMra043172
  5. PADUCH DA, SKOOG SJ. Current Management of Adolescent Varicocele Rev Urol [online] 2001, 3(3):120-133 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476052
  6. AKBAY E, CAYAN S, DORUK E, DUCE MN, BOZLU M. The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents. BJU Int [online] 2000 Sep, 86(4):490-3 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10971279
  7. VAN BATAVIA JP, WOLDU SL, RAIMONDI PM, SPENCER BA, INSEL BJ, POON SA, GLASSBERG KI. Adolescent varicocele: influence of Tanner stage at presentation on the presence, development, worsening and/or improvement of testicular hypotrophy without surgical intervention. J Urol [online] 2010 Oct, 184(4 Suppl):1727-32 [viewed 08 August 2014] Available from: doi:10.1016/j.juro.2010.05.053
  8. DI MAGGIO C, PESCARINI L, TALENTI E, LEMBO A, GUAZZIERI S. [Scrotum transillumination: method and results (author's transl)]. Radiol Med [online] 1981 Oct, 67(10):733-7 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7323336
  9. ZAMPIERI N, ZUIN V, CORROPPOLO M, OTTOLENGHI A, CAMOGLIO FS. Relationship between varicocele grade, vein reflux and testicular growth arrest. Pediatr Surg Int [online] 2008 Jun, 24(6):727-30 [viewed 08 August 2014] Available from: doi:10.1007/s00383-008-2143-7
  10. BELANI JS, YAN Y, NAUGHTON CK. Does varicocele grade predict vein number and size at microsurgical subinguinal repair? Urology [online] 2004 Jul, 64(1):137-9 [viewed 08 August 2014] Available from: doi:10.1016/j.urology.2004.02.006
  11. MAHALIK SK, PRASAD A, BHALLA S, KULSHRESTHA R. Transilluminating testicular mass Indian J Med Paediatr Oncol [online] 2011, 32(1):46-48 [viewed 08 August 2014] Available from: doi:10.4103/0971-5851.81891
  12. NISTAL M, GONZáLEZ-PERAMATO P, SERRANO A, REGADERA J. [Physiopathology of the infertile testicle. Etiopathogenesis of varicocele]. Arch Esp Urol [online] 2004 Nov, 57(9):883-904 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15624389
  13. CAYAN S, AKBAY E, BOZLU M, DORUK E, YILDIZ A, ACAR D, KANIK EA, ULUSOY E. Diagnosis of pediatric varicoceles by physical examination and ultrasonography and measurement of the testicular volume: using the prader orchidometer versus ultrasonography. Urol Int [online] 2002, 69(4):293-6 [viewed 08 August 2014] Available from: doi:66125
  14. BAISHYA RK, DHAWAN DR, SABNIS R, DESAI MR. Testicular volume in adolescent varicocele Indian J Radiol Imaging [online] 2011, 21(1):69 [viewed 08 August 2014] Available from: doi:10.4103/0971-3026.76064

Differential Diagnoses

Fact Explanation
Hydrocele[1] Hydrocele is a condition associated with an abnormal collection of serous fluid in between the parietal and visceral layers of the tunica vaginalis. On examination it is a hemiscrotal swelling with soft, nontender, transilluminating lump and testis cannot palpated separately.
Epididymal cyst[2] It is a cyst arising in the epididymis. They are cystic, fluid filled, well defined, fluctuant and will transilluminate. The testis is palpable separately and there may be a gap between the cyst and the testis.
Testicular carcinoma[3] Tumors that arise from the testis are a painless swelling or nodule of one testicle, usually hard and irregular, which can not be separated from the testis.
Spermatocele[4] This is a benign cystic accumulation of sperm and it arises from the head of the epididymis. They are smooth, spherical and transilluminating lump found superior to the testicle.
Indirect inguinal hernia[5] This occurs due to the internal opening of the inguinal canal which allows intestine to herniate through the inguinal canal. It can extend into the scrotum. Physical findings are: expansile cough impulse, reducibility, soft consistency and the lump being separable from the testis are examination findings.
References
  1. CIMADOR M, CASTAGNETTI M, DE GRAZIA E. Management of hydrocele in adolescent patients. Nat Rev Urol [online] 2010 Jul, 7(7):379-85 [viewed 08 August 2014] Available from: doi:10.1038/nrurol.2010.80
  2. ERIKCI V, HOşGöR M, AKSOY N, OKUR Ö, YILDIZ M, DURSUN A, DEMIRCAN Y, ÖRNEK Y, GENIşOL İ. Management of epididymal cysts in childhood. J Pediatr Surg [online] 2013 Oct, 48(10):2153-6 [viewed 08 August 2014] Available from: doi:10.1016/j.jpedsurg.2013.01.058
  3. CIFTCI AO, BINGöL-KOLOğLU M, SENOCAK ME, TANYEL FC, BüYüKPAMUKçU M, BüYüKPAMUKçU N. Testicular tumors in children. J Pediatr Surg [online] 2001 Dec, 36(12):1796-801 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11733909
  4. RIOJA J, SáNCHEZ-MARGALLO FM, USóN J, RIOJA LA. Adult hydrocele and spermatocele. BJU Int [online] 2011 Jun, 107(11):1852-64 [viewed 08 August 2014] Available from: doi:10.1111/j.1464-410X.2011.10353.x
  5. GASPAR MR, WOOLLEY MM, JOERGENSON EJ. SLIDING INDIRECT INGUINAL HERNIA Calif Med [online] 1956 Nov, 85(5):330-334 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1532016

Investigations - for Diagnosis

Fact Explanation
Ultrasonography [1] with color flow Doppler imaging [2] High resolution color-flow Doppler scrotal ultrasonography[3] is the diagnostic investigation of choice. This is done in upright position during a Valsalva maneuver.It reveals the presence of tortuous anechoic tubular structures adjacent to the testis.Color Doppler imaging will be helpful with differentiatiation of venous channels from spermatoceles or epidermoid cysts upon any doubt. Doppler ultrasonography also useful in grading. USS KUB should be consider when a patient present with: a single right-sided varicocelem sudden onset of a varicocele or any that is not reducible when supine. Because in these situations retroperitoneal pathology should be considered (i.e. renal cell carcinoma) causing spermatic vein compression.
Computed Tomography (CT Scan) [7] or Magnetic Resonance Imaging (MRI)[8] Varicoceles can be demonstrated by CT or MRI scans. When patient is suspected to have renal cell carcinoma or an adrenocortical tumor or if the patient is presents with recurrent varicocele CT or MRI scanning is helpful before repairing the varicocele.
Nuclear Imaging[3] As there is a pooling of blood in the pampiniform venous plexus, nuclear imaging can be used in diagnosis. Technetium-99m (99m Tc)–labeled red blood cells are the radiopharmaceutical agent used here. Images are taken in both the supine and erect positions. Intrascrotal accumulation of the labeled red cells will confirm the diagnosis.
Angiography[5] Venography is the best investigation in diagnosis of small or a subclinical varicocele. ( <2.7mm).
Scrotal Thermography[4][6] This test can identify the difference in temperature of at least 2.8°C (5°F) between abnormal and normal sides in varicocele. It is impossible to distinguish between intrascrotal tumor, inflammation, or varicocele on the basis of thermographic findings.
References
  1. ORDA R, SAYFAN J, MANOR H, WITZ E, SOFER Y. Diagnosis of varicocele and postoperative evaluation using inguinal ultrasonography. Ann Surg [online] 1987 Jul, 206(1):99-101 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492929
  2. CHIOU RK, ANDERSON JC, WOBIG RK, ROSINSKY DE, MATAMOROS A JR, CHEN WS, TAYLOR RJ. Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination. Urology [online] 1997 Dec, 50(6):953-6 [viewed 08 August 2014] Available from: doi:10.1016/S0090-4295(97)00452-4
  3. GONDA RL JR, KARO JJ, FORTE RA, O'DONNELL KT. Diagnosis of subclinical varicocele in infertility. AJR Am J Roentgenol [online] 1987 Jan, 148(1):71-5 [viewed 08 August 2014] Available from: doi:10.2214/ajr.148.1.71
  4. GOLD RH, EHRLICH RM, SAMUELS B, DOWDY A, YOUNG RT. Scrotal thermography. Radiology [online] 1977 Jan, 122(1):129-32 [viewed 08 August 2014] Available from: doi:10.1148/122.1.129
  5. MOON KH, CHO SJ, KIM KS, PARK S, PARK S. Recurrent Varicoceles: Causes and Treatment Using Angiography and Magnification Assisted Subinguinal Varicocelectomy Yonsei Med J [online] 2012 Jul 1, 53(4):723-728 [viewed 08 August 2014] Available from: doi:10.3349/ymj.2012.53.4.723
  6. KULIS T, KOLARIC D, KARLOVIC K, KNEZEVIC M, ANTONINI S, KASTELAN Z. Scrotal infrared digital thermography in assessment of varicocele--pilot study to assess diagnostic criteria. Andrologia [online] 2012 May:780-5 [viewed 08 August 2014] Available from: doi:10.1111/j.1439-0272.2011.01265.x
  7. KARCAALTINCABA M. Demonstration of normal and dilated testicular veins by multidetector computed tomography. Jpn J Radiol [online] 2011 Apr, 29(3):161-5 [viewed 08 August 2014] Available from: doi:10.1007/s11604-010-0527-9
  8. KARAKAS E, KARAKAS O, CULLU N, BADEM OF, BOYACı FN, GULUM M, CECE H. Diffusion-weighted MRI of the testes in patients with varicocele: a preliminary study. AJR Am J Roentgenol [online] 2014 Feb, 202(2):324-8 [viewed 08 August 2014] Available from: doi:10.2214/AJR.13.10594

Investigations - Fitness for Management

Fact Explanation
Seminal Fluid Analysis(SFA)[1][2] It has been found that there is an increased number of abnormal forms, increased number of tapered forms/immature cells, decreased motility and lower mean sperm counts are associated with varicocele. However the SFA results are not diagnostic of varicocele.
Full blood count This is useful in assessing the patient's general condition and it also helpful in assessing the patients platelet counts before surgical treatment [3].
References
  1. SCHAUER I, MADERSBACHER S, JOST R, HüBNER WA, IMHOF M. The impact of varicocelectomy on sperm parameters: a meta-analysis. J Urol [online] 2012 May, 187(5):1540-7 [viewed 08 August 2014] Available from: doi:10.1016/j.juro.2011.12.084
  2. PIERIK FH, VREEBURG JT, STIJNEN T, VAN ROIJEN JH, DOHLE GR, LAMéRIS JS, TIMMERS T, WEBER RF. Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography. Int J Androl [online] 1998 Oct, 21(5):256-60 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9805240
  3. GROBER ED, CHAN PT, ZINI A, GOLDSTEIN M. Microsurgical treatment of persistent or recurrent varicocele. Fertil Steril [online] 2004 Sep, 82(3):718-22 [viewed 08 August 2014] Available from: doi:10.1016/j.fertnstert.2004.03.028

Investigations - Followup

Fact Explanation
Ultrasonography[3] with color flow Doppler imaging This is useful in assessing the patient after treatment for improvement or for assessment of a recurrence.
Seminal Fluid Analysis(SFA)[1][2] Several studies have evaluated the effects of varicocelectomy on semen parameters and they are shown an improvement in sperm density with or without an increase in sperm motility and morphology.
References
  1. SCHAUER I, MADERSBACHER S, JOST R, HüBNER WA, IMHOF M. The impact of varicocelectomy on sperm parameters: a meta-analysis. J Urol [online] 2012 May, 187(5):1540-7 [viewed 08 August 2014] Available from: doi:10.1016/j.juro.2011.12.084
  2. PIERIK FH, VREEBURG JT, STIJNEN T, VAN ROIJEN JH, DOHLE GR, LAMéRIS JS, TIMMERS T, WEBER RF. Improvement of sperm count and motility after ligation of varicoceles detected with colour Doppler ultrasonography. Int J Androl [online] 1998 Oct, 21(5):256-60 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9805240
  3. ZAUPA P, MAYR J, HöLLWARTH ME. Antegrade scrotal sclerotherapy for treating primary varicocele in children. BJU Int [online] 2006 Apr, 97(4):809-12 [viewed 08 August 2014] Available from: doi:10.1111/j.1464-410X.2006.06033.x

Investigations - Screening/Staging

Fact Explanation
Ultrasonography[1] with color flow Doppler imaging[2] This is useful in grading the varicocele according to the internal diameter of the blood vessels in pampiniform plexus.
References
  1. ORDA R, SAYFAN J, MANOR H, WITZ E, SOFER Y. Diagnosis of varicocele and postoperative evaluation using inguinal ultrasonography. Ann Surg [online] 1987 Jul, 206(1):99-101 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492929
  2. CHIOU RK, ANDERSON JC, WOBIG RK, ROSINSKY DE, MATAMOROS A JR, CHEN WS, TAYLOR RJ. Color Doppler ultrasound criteria to diagnose varicoceles: correlation of a new scoring system with physical examination. Urology [online] 1997 Dec, 50(6):953-6 [viewed 08 August 2014] Available from: doi:10.1016/S0090-4295(97)00452-4
  3. PAUROSO S, DI LEO N, FULLE I, DI SEGNI M, ALESSI S, MAGGINI E. Varicocele: Ultrasonographic assessment in daily clinical practice J Ultrasound [online] , 14(4):199-204 [viewed 08 August 2014] Available from: doi:10.1016/j.jus.2011.08.001
  4. TRPKOV K, GRIGNON DJ, BONSIB SM, AMIN MB, BILLIS A, LOPEZ-BELTRAN A, SAMARATUNGA H, TAMBOLI P, DELAHUNT B, EGEVAD L, MONTIRONI R, SRIGLEY JR, MEMBERS OF THE ISUP RENAL TUMOR PANEL. Handling and staging of renal cell carcinoma: the International Society of Urological Pathology Consensus (ISUP) conference recommendations. Am J Surg Pathol [online] 2013 Oct, 37(10):1505-17 [viewed 08 August 2014] Available from: doi:10.1097/PAS.0b013e31829a85d0

Management - General Measures

Fact Explanation
Pain management[1] When varicoceles cause minor discomfort but doesn't affect fertility, they can be managed with painkillers such as paracetamol and ibuprofen. Advise patients to wear an athletic support or a properly fitting undergarment will useful in relieving pain by reducing the pressure.
References
  1. CHAN P. Management options of varicoceles Indian J Urol [online] 2011, 27(1):65-73 [viewed 08 August 2014] Available from: doi:10.4103/0970-1591.78431

Management - Specific Treatments

Fact Explanation
Surgical repair of varicocele[1] Surgical repair can be done via a open varicocelectomy (retroperitoneal high ligation, inguinal and sub-inguinal ligation). Alternatives are laparoscopic or robotic varicocelectomy and microsurgical varicocelectomy.Open surgery can be done as an outpatient procedure using general anesthetic or local anesthetic. Following surgery patients should be advised to avoid: strenuous activities for two days and strenuous activity for two weeks. Laparoscopic surgery requires general anesthesia. Microsurgical varicocelectomy can be performed under local, regional or general anesthesia and this also done as an OPD procedure.
Percutaneous occlusion of varicocele by intravenous injection [1] Here percutaneous embolization of the gonadal vein is done especially for persistent/recurrent varicoceles following surgery. There are two procedures that can be performed; traditional retrograde occlusion and the antegrade technique. In the retrograde technique right femoral vein is punctured and angiocatheter is inserted to the internal spermatic vein via inferior vena cava and the left renal vein. Then sclerosing agents, detachable coils or occlusive balloons are used. In the percutaneous antegrade varicocele occlusion injection of sclerosing agents are directly given to an isolated vein from the pampiniform plexus (fluoroscopically drainage should be confirmed before injection).
References
  1. CHAN P. Management options of varicoceles Indian J Urol [online] 2011, 27(1):65-73 [viewed 08 August 2014] Available from: doi:10.4103/0970-1591.78431