What is the diagnosis and treatment for a prominent pampiniform plexus suggestive of varicocele?

Diagnosis and Treatment of Prominent Pampiniform Plexus (Varicocele)

A prominent pampiniform plexus is diagnostic of varicocele, which should be treated with microsurgical varicocelectomy in infertile men with abnormal semen parameters to improve fertility rates. 1, 2

Diagnosis of Varicocele

• Varicocele is defined as pathologically enlarged, tortuous veins of the pampiniform plexus within the spermatic cord 3, 4
• Prevalence is approximately 15% in the general male population, but 40% in men with primary infertility and 80% in men with secondary infertility 2, 5
• Clinical presentation may include:
  • Palpable thickening in the scrotum 4
  • Dull scrotal or inguinal pain that worsens when standing or during erection 4
  • Often asymptomatic and discovered during routine examination 3

Diagnostic Evaluation

• Physical examination is the primary diagnostic method, involving palpation of the scrotum at rest and during Valsalva maneuver 4
• Scrotal Doppler ultrasound should be performed to:
  • Confirm the grade of varicocele
  • Evaluate blood flow patterns
  • Particularly useful in patients where physical examination is difficult (e.g., obese patients) 6
• Important: Routine use of ultrasonography to identify non-palpable varicoceles is discouraged as treatment of these varicoceles is not associated with improvement in semen parameters or fertility rates 1, 6

Special Considerations

• If varicocele is on the right side, no routine abdominal imaging is necessary unless it's a new onset or non-reducible varicocele 1, 6
• For sudden onset of varicocele in elderly men, abdominal imaging should be considered to exclude renal tumor 4

Treatment Approach

When to Treat

• Do not treat varicocele in men who have:
  • Normal semen analysis
  • Subclinical (non-palpable) varicocele 1
• Treat varicocele in:
  • Infertile men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility, especially when the female partner has good ovarian reserve 1
  • Adolescents with varicocele associated with a persistent small testis (size difference >2 ml or 20%), confirmed on two subsequent visits 6 months apart 1

Treatment Options

• Microsurgical varicocelectomy (subinguinal or inguinal approach):

  • Appears to be the optimal treatment in most cases 2
  • Results in improvement in both semen quality and fertility 1
  • Scrotal ultrasound can be used before repair to confirm the presence of varicocele and after correction to determine procedural success 1

• Alternative procedures (useful in specific cases):

  • Laparoscopic varicocelectomy (more common in adolescents) 3
  • Radiological percutaneous embolization (minimally invasive option requiring only minimal sedation) 2, 5

Post-Treatment Expectations

• It typically takes 3-6 months for patients' semen parameters to improve after varicocele repair 2
• If infertility persists after this interval, other therapies including assisted reproductive technology should be considered, especially in older couples 2

Special Clinical Scenarios

• Varicocelectomy for men with elevated sperm DNA fragmentation:

  • May be considered in men with otherwise unexplained infertility and those with failure of assisted reproductive techniques, including recurrent pregnancy loss and failure of embryogenesis and implantation 1

• Varicocele and azoospermia:

  • Onco-TESE (testicular sperm extraction) at the time of radical orchidectomy should be offered in men with testicular cancer and azoospermia or severe abnormalities in semen parameters 1

Potential Complications

• Varicocele can impair spermatogenesis through:
  • Increased testicular temperature
  • Adrenal metabolite reflux into the testes 4
• If left untreated, varicocele may cause testicular atrophy with impaired sperm production and decreased Leydig cell function in some males 3

Remember that while varicoceles are common, only about 20% of men with a documented varicocele will suffer fertility problems 2, 3. Treatment should be targeted to those who will benefit most.