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 Prognosis