Characteristics of a Varicocele
Varicoceles are abnormal dilations of the pampiniform plexus of veins within the scrotum that affect up to 15% of men in the general population and are the most common diagnosis in infertile men, affecting 35-40% of this population. 1, 2
Definition and Prevalence
- Abnormal dilation of the veins within the scrotum (pampiniform plexus)
- Prevalence: 8-15% in healthy men
- Higher prevalence (35-80%) in men with primary or secondary infertility 3, 2
- Most common diagnosis in men presenting to fertility clinics 4
Clinical Presentation
Physical Characteristics
- Often described as feeling like a "bag of worms" in the scrotum 3
- Most commonly occurs on the left side (due to anatomical factors)
- Can be unilateral or bilateral
- Classified by grade:
- Grade 1: Palpable only during Valsalva maneuver
- Grade 2: Palpable without Valsalva
- Grade 3: Visible through scrotal skin
Symptoms
- Often asymptomatic
- May present with:
Diagnostic Approach
Physical Examination
- Primary diagnostic method is physical examination 4
- Should be performed with the patient standing
- Examination should include:
- Visual inspection of the scrotum
- Palpation of the spermatic cord with and without Valsalva maneuver
- Assessment of testicular size and consistency
Imaging
- Color Doppler ultrasound can confirm diagnosis when physical examination is inconclusive 2
- Routine use of ultrasonography to investigate presumed varicocele is discouraged, as treatment of non-palpable varicoceles is not associated with improvement in either semen parameters or fertility rates 1
- Scrotal ultrasound may be used before repair to confirm presence and after correction to determine procedural success 1
Important Considerations
- Clinicians should not routinely perform abdominal imaging for isolated small or moderate right varicocele 1
- A common clinical misconception is that right-sided varicoceles require abdominal imaging to rule out retroperitoneal pathology, but evidence does not support this practice 1
Clinical Significance
Impact on Male Fertility
- Associated with:
- Treatment of clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor 1
Other Clinical Implications
- May cause progressive testicular damage if left untreated
- Can lead to reduced testosterone production
- In adolescents, may cause testicular growth retardation 4
Rare Complications
- Spontaneous or traumatic rupture resulting in:
- Spermatic cord hematoma
- Scrotal hematoma 6
- Post-varicocelectomy complications may include:
- Persistent scrotal pain
- Recurrence of varicocele
- Development of hydrocele
- Neuralgia 3
Treatment Options
- Conservative management for mild symptoms
- Surgical correction (varicocelectomy) via several approaches:
- Inguinal approach (preferred when no history of inguinal surgery)
- Subinguinal approach
- Laparoscopic approach
- Microsurgical techniques with operating microscope and micro Doppler probe 4
- Radiographic venous embolization as an alternative to surgery 5
Clinical Pitfalls to Avoid
- Treating non-palpable (subclinical) varicoceles - evidence does not support improvement in fertility outcomes
- Unnecessary abdominal imaging for isolated right varicoceles
- Overlooking varicocele in infertile men during physical examination
- Failing to consider varicocele as a cause of testicular atrophy in adolescents
- Not recognizing that varicocele correction is more cost-effective than assisted reproductive techniques like IUI and IVF for affected couples 5
Varicoceles remain the most surgically treatable form of male infertility, with proper diagnosis and surgical correction offering the best chance for improved semen parameters and fertility outcomes.