Updated: 4/25/2019

Varicocele

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Questions
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Evidence
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Overview
 

 
Snapshot
  • A 34-year-old man presents to the fertility clinic for evaluation of infertility. His him and his wife have been trying to have children for 2 years. His wife was recently evaluated and found to be normal and healthy. The patient denies any pain in his testicular region. However, he reports occasional feelings of heaviness in his scrotum. On physical exam, his scrotum looks distended. Valsalva maneuvers result in a "bag of worm"-like finding upon palpation of the testicle.
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
      • retroperitoneal tumor
      • portal hypertension 
  • 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
      • atrophy or hypotrophy
      • infertility
  • Physical exam
    • standing or valsalva maneuver
      • distension on inspection
      • “bag of worms” on palpation
    • illumination test with light
      • scrotum does not transilluminate
Imaging
  • Ultrasound with doppler
    • indications
      • if varicocele is suspected but physical exam is inconclusive
    • findings
      • dilatation of vessels of pampiniform plexus > 2 mm
      • reflux in pampiniform plexus
    • sensitivity and specificity
      • both 100%
  • CT abdomen with contrast 
    • indications
      • IVC obstruction
        • right-sided varicovele
        • bilateral varicocele
        • failure of varicocele to disappear when laying supine
    • findings
      • IVC thrombosis or compression
Studies
  • Semen analysis
    • to test for complications of varicocele (e.g., infertility)
Differential
  • Hydrocele      
    • positive transillumination test
  • Testicular torsion
    • abnormal cremasteric reflex
Treatment
  • Conservative
    • monitor with annual exams 
      • indications
        • asymptomatic patients
        • no testicular hypotrophy
  • Operative
    • surgical ligation or embolization
      • indications
        • pain
        • infertility
        • delayed growth of testes
      • outcomes
        • in terms of fertility, 40% of couples recover with successful pregnancy
Complications
  • Infertility due to increased temperature of scrotum
  • Testicular atrophy
 

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Questions (2)

(M3.RL.16.4) A 14-year-old male patient, with no past medical history, presents to the clinic with 2-months of pain in his lower abdomen. Upon further questioning he states that the pain is a dull and a 2/10 in severity that worsens the longer he stands. The pain goes away when he lies down. The patient is not sexually active and has had no recent trauma. His vital signs are all within normal limits. On physical exam you note a palpable and slightly tender mass on his left testicle. An ultrasound of the mass is performed and can be seen in Figure A. What is a potential seqelae of this issue if left untreated? Tested Concept

QID: 102722
FIGURES:
1

Testicular necrosis

25%

(2/8)

2

Testicular abscess

0%

(0/8)

3

Testicular atrophy

38%

(3/8)

4

Intestinal necrosis

12%

(1/8)

5

Testicular rupture

25%

(2/8)

M 12 E

Select Answer to see Preferred Response

(M3.RL.15.6) A 28-year-old man presents to a urologist upon referral from a fertility medicine specialist who evaluated the patient and his wife. The patient was told that he had a low sperm count. Otherwise, the patient endorses dull and low grade testicular pain that is chronic in nature and unchanged from his baseline. The patient's vitals are unremarkable. Examination and palpation of the right scrotum and testicle reveals soft palpable cords on the right side which are not seen on the left. Additionally, the examination reveals right testicular atrophy. When the patient lies supine, there is no change in the appearance or size of the scrotum. An ultrasound and color Doppler study of the patient's right testicle is shown in Figure A. Which of the following is the best next step in the management for this patient? Tested Concept

QID: 102724
FIGURES:
1

CT abdomen and pelvis

11%

(1/9)

2

Embolization

44%

(4/9)

3

MRI pelvis

0%

(0/9)

4

Observation

11%

(1/9)

5

Surgical repair

33%

(3/9)

M 10 E

Select Answer to see Preferred Response

Evidence (3)
Topic COMMENTS (7)
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