Samuel Ohlander, MD
Craig S. Niederberger, MD, FACS
BASICS
DESCRIPTION
• Varicocele is an abnormal dilation of the pampiniform plexus of veins situated within the spermatic cord
• Can be asymptomatic, cause discomfort and may impact spermatogenesis.
• Clinical grading of varicoceles:
– Subclinical: Nonpalpable
– Grade I: Small, not grossly visible, palpated only during Valsalva
– Grade II: Moderate size, not grossly visible, easily palpated in standing position without Valsalva
– Grade III: Large and grossly visible while standing
• Only palpable are clinically relevant
• If prior to puberty or unilateral right varicocele, suggests underlying pathology (See Varicocele, Pediatric)
EPIDEMIOLOGY
Incidence
• Decrease in incidence with increasing body mass index (BMI)
• Increased (3–8x) among 1st-degree relatives with varicocele (1)
Prevalence
• 15% of males
• Majority left sided (75–90%), 33% bilateral
• Seen in 35–40% of men presenting with primary infertility vs. 70–80% with secondary infertility (infertility after previously conceiving a child)
– Not causative of infertility in the majority of men
RISK FACTORS
• Congenital absence of valves in spermatic vein
• Acquired incompetence of valves, extrinsic compression increasing intravascular pressure (eg, retroperitoneal pathologic process)
Genetics
Ongoing area of research
PATHOPHYSIOLOGY
• Varices
– Due to absent or incompetent venous valves in spermatic veins allowing retrograde flow
– May be congenital or acquired
– Thought to be due to right-angle insertion of left spermatic vein into left renal vein resulting in turbulent flow and increased intravascular back pressure
– Extrinsic compression
Mass
“Nutcracker effect”: Left renal vein compressed between superior mesenteric artery and the aorta producing elevated left gonadal vein pressures
• Infertility due to varicoceles:
– Poorly defined, many theories
Increased intratesticular temperature compared to controls (0.6–0.8 C)
Loss of countercurrent testicular cooling mechanism
Elevated temperature reduces testosterone synthesis by Leydig cells, injures germinal cell membranes, alters protein metabolism, and reduces Sertoli cell function
Increased testicular hypoxia and oxidative stress due to impaired venous drainage (possibly affecting Leydig cells, DNA fragmentation)
Reflux of gonadotoxic renal and adrenal metabolites
– Can alter spermatogenesis
– Decreased sperm quality (concentration, motility, morphology, DNA integrity)
ASSOCIATED CONDITIONS
• Infertility
• Testicular atrophy
• Rarely, tumor, renal vein thrombus
GENERAL PREVENTION
None
DIAGNOSIS
ALERT
Acute onset suggests obstruction of renal or gonadal vein (possibly secondary to tumor).
HISTORY
• Infertility
• Pain
– Most asymptomatic
– Dull ache, heavy sensation, sensation of increased heat
– Increases with activity (including intercourse), standing, and with Valsalva
– Relieved by recumbency
PHYSICAL EXAM
• Gold standard for diagnosis
– Examine in a warm room after patient has been standing for 10 min
– Examine with patient supine and standing upright, with performing Valsalva while in upright position
– Palpation described as “bag of worms”
– See subheading “Basics, description” for grading
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Semen analysis (SA)
– 2–3 days of sexual abstinence prior to collection
– “Stress pattern” on SA
– Concentration <20 million/mL; motility <60%; morphology <14% strict normal forms (oligoasthenoteratospermia or OAT)
• FSH >4.5 & OAT indicates varicocele may be impacting sperm production
Imaging
• Radiographic testing should only be used when presence is uncertain on physical exam (eg, obesity), recurrence is suspected, or varicocele is present after treatment. (2)[C]
• Ultrasound:
– Helps exclude other intrascrotal pathology
– Varicocele defined as dilation of pampiniform plexus veins with Valsalva to caliber of >3 mm with and/or reversal of flow with Valsalva during color Doppler
• Internal spermatic venography:
– Potentially diagnostic and therapeutic
– Only used for recurrent varicoceles
– Invasive
• Abdominal imaging if renal or other retroperitoneal mass suspected of causing varicocele
Diagnostic Procedures/Surgery
Venography, as described above
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Spermatic cord mass:
– Adenomatoid tumor of the cord
– Epidermoid cyst
– Epididymitis/epididymo-orchitis
– Fibrous pseudotumor
– Hernia
– Hemangioma
– Hydrocele/hydrocele of the cord
– Inguinal lymphadenopathy
– Leiomyoma
– Malignant tumor (liposarcoma, rhabdomyosarcoma, leiomyosarcoma, malignant histiocytoma)
– Metastasis
– Polyorchidism
– Sarcoid
– Sperm granuloma
– Spermatocele
– Testis tumor
– Undescended/retractile testicle
– Vasitis and vasitis nodosa (typically associated with epididymitis)
ALERT
Suspect renal or retroperitoneal tumor if varicocele is exclusively right sided or remains engorged when the patient is placed in the supine position.
TREATMENT
GENERAL MEASURES
• Subclinical varicoceles have questionable impact on fertility, and repair may not improve fertility rates (3)[B]
• NSAIDs and ice may provide symptomatic relief
• Indications for treatment of infertile male (should meet all criteria):
– Varicocele palpable on exam
– Man with abnormal semen parameters or abnormal sperm function tests
– Couple with known infertility
– Female has normal or potentially treatable cause of infertility
– Treatment will enable natural pregnancy or less invasive assisted reproductive techniques (ART) eg, intrauterine insemination (IUI)
• Surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen parameters (4)[A].
• Pain from symptomatic varicocele or testicular atrophy (>15–20%) are also indications for repair
MEDICATION
First Line
Pain: Analgesics (eg, NSAIDs) usually not durable therapy
Second Line
None
SURGERY/OTHER PROCEDURES
• Surgical treatment successfully eliminates over 90% of varicoceles
• Bilateral repair warranted when varicoceles are noted on both sides in presence of elevated FSH and testicular hypotrophy
• Operative intervention classified by anatomic site of varix ligation and surgical technique
• Anatomic site of ligation:
– Subinguinal microsurgical: The standard in recent years, incision over the cord below the external ring
Number of veins requiring ligation is greater
Microscope and Doppler to protect spermatic artery and lymphatics
Recurrence rates ∼1%
Hydrocele rates <1%
– Inguinal: Inguinal incision, ligation of spermatic veins within inguinal canal
Allows for concurrent hernia repair
Recurrence rates up to 16%
Hydrocele rate up to 30% if nonmicrosurgical
– Scrotal: The transcrotal approach is considered obsolete
– Retroperitoneal (Palomo or high ligation): Muscle splitting incision, exposure of spermatic vessels with or without preservation of spermatic artery
Mass ligation permitted due to presence of collateral arterial circulation (vasal, cremasteric artery)
Recurrence rates 15–25%
Hydrocele rate ∼7%
• Surgical technique:
– Open with or without magnification:
Magnification preferred to spare arteries and lymphatics, and allow ligation of small venous tributaries
Subinguinal or inguinal microscopic varicocelectomy offers the best overall outcome (5)[A]
– Laparoscopic:
High ligation
Recurrence rates <2%
Hydrocele rate 5–8%
5% of patients experience transient anterior thigh numbness
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Interventional radiology:
– Used as a 2nd-line therapy for those who fail surgery
– Venography with access through the femoral or internal jugular vein
– Occlusion therapy (sclerotherapy, embolization)
– Quicker recovery (3–4 days) but higher recurrence rate (up to 27%)
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• See “Surgery/Other Procedures” for recurrence rates of individual techniques
• Pain or relief of pain typically immediate after recovery from surgery
COMPLICATIONS
• See “Surgery/Other Procedures” for treatment specific complication rates
• Hydrocele
• Recurrence
• Testicular artery injury
• Nerve injury
• Testicular atrophy
FOLLOW-UP
Patient Monitoring
• Varicocele recurrence:
– Typically evident within 6–13 mo
• Infertility:
– Semen analysis (SA) at 3-mo intervals; semen should be monitored for at least 1 yr or until pregnancy has been achieved
– Young men with varicocele and normal SA should be followed with testis size SA and FSH every 1–2 yr
Patient Resources
• www.maledoc.com Urologist maintained male infertility, potency, and health blog
• Urology Care Foundation: Varicoceles http://www.urologyhealth.org/urology/index.cfm?article=116
REFERENCES
1. Raman, JD, Walmsley K, Goldstein M. Inheritance of varicoceles. Urology, 2005;65(6):1186–1189.
2. American Urological, Inc. and American Society for Reproductive Medicine. Report on varicocele and infertility: AUA best practice statement . Linthicum (MD): American Urological Association Education and Research, Inc.; 2011.
3. Jarow JP, Ogle SR, Eskew LA. Seminal improvement following repair of ultrasound detected subclinical varicoceles. J Urol. 1996;155(4):1287–1290.
4. Agarwal A, Deepinder F, Cocuzza M, et al. Efficacy of varicocelectomy in improving semen parameters: New meta-analytical approach. Urology. 2007;70(3):532–538.
5. Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele review in infertile men: A meta-analysis to define the best technique. J Androl. 2009;30:33–40.
ADDITIONAL READING
• Lee J, Binsaleh S, Lo K, et al. Varicoceles: The diagnostic dilemma. J Androl. 2008;29(2):143–146.
• Practice Committee of American Society for Reproductive Medicine. Report on varicocele and infertility. Fertil Steril. 2008;90(5 Suppl):S247–S249.
• Ross AE, Burnett AL. Varicocele-adult. In: Gomella LG, ed. The 5-Minute Urology Consult. 2nd ed. Philadelphia, PA: Lippincott; 2009.
• Sabanegh E, Agarwal A. Male Infertility. In: Wein AJ, Kavoussi LR, Novick AC, et al., eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Saunders; 2012.
• Will MA, Swain J, Fode M, et al. The great debate: Varicocele treatment and impact on fertility. Fertil Steril. 2011;95(3):841–852.
See Also (Topic, Algorithm, Media)
• Infertility, Urologic Considerations
• Spermatic Cord Mass and Tumors
• Varicocele, Adult Image 
• Varicocele, Pediatric
CODES
ICD9
• 456.4 Scrotal varices
• 752.89 Other specified anomalies of genital organs
ICD10
• I86.1 Scrotal varices
• Q64.8 Other specified congenital malformations of urinary system
CLINICAL/SURGICAL PEARLS
• Majority of varicoceles are left sided (75–90%) with diagnosis by physical exam.
• Subclinical (nonpalpable) varicoceles have questionable impact on fertility, and repair may not improve fertility rates.
• Suspect renal or retroperitoneal tumor if varicocele is acute in onset, exclusively right sided or remains engorged when the patient is placed in the supine position.
• Subinguinal microscopic varicocelectomy offers the best overall outcome, though approach should depend on surgeon comfort.