Varicocele

Background

Scrotal anatomy

Cross section showing the pampiniform venus plexus.

• Peak incidence: onset of puberty
• Dilatation of spermatic cord veins (pampiniform plexus)
  • ~90% occur on left due to 90 degree turn of left testicular vein into left renal vein
  • R testicular vein drains into IVC
    • If right-sided, consider inferior vena cava thrombosis
• Can impair sperm production/function leading to infertility
• Sudden appearance may be related to renal malignancy obstructing venous return

Clinical Features

Varicocele on left

• Scrotal mass and discomfort (dullness/heaviness)
• Physical exam
  • "Bag of worms"
  • More prominent with standing or Valsalva
  • Does not trans-illuminate

Differential Diagnosis

Testicular Diagnoses

• Scrotal cellulitis
• Epididymitis
• Fournier gangrene
• Hematocele
• Hydrocele
  • Hydrocele (peds)
• Indirect inguinal hernia
• Inguinal lymph node (Lymphadenitis)
• Orchitis
• Scrotal abscess
• Spermatocele
• Tinea cruris
• Testicular rupture
• Testicular torsion
• Testicular trauma
• Testicular tumor
• Torsion of testicular appendage
• Varicocele
• Pyocele
• Testicular malignancy
• Scrotal wall hematoma

Evaluation

Testicular ultrasound showing left varicocele.

Workup

• Consider UA
• Consider testicular ultrasound

Diagnosis

• May be clinical vs. based on ultrasound

Management

• Scrotal support (for symptomatic relief)

Disposition

• Discharge with urology referral
  • Implications of possible subfertility should be discussed with patient by urologist

See Also

• Testicular Diagnoses