Varicocele is defined as a dilation of the pampiniform plexus of the veins within and surrounding the spermatic cord secondary to absent or incompetent venous values, which are congenital or acquired, respectively. Varicoceles maybe visible, nonvisible but palpable (the classic sign is the so-called scrotal "bag of worms", referring to vermiform appearance of the dilated veins), or nonvisible and nonpalpable. Both adults and children present as a scrotal emergency with a varicocele. Varicoceles are more common on the left, which is thought to be due to increased venous pressure. The classic teaching is that an isolated right varicoceles should prompt a search for abdominal pathology such as renal tumors with vena caval thrombus, retroperito-neal fibrosis, renal vein thrombosis and retroperitoneal cancers. Multiple teleological arguments have been invoked, including of a longer drainage path of the left gonadal vein, a right angle entry into the left renal vein, erect posture of humans (four-legged animals do not get varicoceles), compression of the left renal vein by the superior mesenteric artery, and a lack of venous valves in the proximal testicular vein.

Table 3. Grades of varicoceles. Traditional grading is on the basis of physical examination, but many are now seen on ultrasound (grade 0)

Grade Description


Not detected on physical exam, but on ultrasound with:

Dilated pampiniform plexus veins to > 2mm and/or Blood flow reversal during Valsalva maneuver seen on Doppler


Palpable on Valsalva


Palpable without need for Valsalva


visible on scrotal inspection alone

Varicoceles can be seen in 15 % of adult males, depending on the definition of varicocele. Most times varicoceles present because of symptoms, but the bulk of men withvaricoceles are asymptomatic. Interestingly, infertile males do have 40 % incidence of varicoceles. If patients do have symptomatic varicoceles, symptoms are usually a pulling sensation or a dull ache that does not radiate. These symptoms are relieved by achieving a recumbent position. The pain is never present on awakening from sleep, but increases over the day, especially with exertion. In a pediatric population, there may be ipsilateral testicular growth retardation from the vari-cocele.

Examination for a varicocele should be conducted in a warm room with the patient in a standing position for 5-10 min before the examination starts, so that the pampiniform plexus veins fill and demonstrate the var-icocele. A varicocele is felt as a mass separate from the testicle. There are usually three grades of varicocele on examination, although with the adjunctive use of ultrasound, there are essentially four grades of varicoceles (see Table 12.3). Varicoceles should get larger with Val-salva maneuvers.

Treatment should be offered for multiple indications. Primarily, treatment is given for patients with complaints of signs or symptoms of the varicocele. Adolescents are offered varicocele repair if there is testicular growth retardation secondary to the varicocele. Finally, patients with male factor infertility due to abnormal semen analysis with a varicocele are offered repair (Cayan et al. 2002). Surgical approaches to repair are either suprainguinal (Palomo repair), inguinal, or subinguinal. Magnification is very helpful to avoid inadvertent ligation of the testicular artery and lymphatics. Ligation of lymphatics is likely to cause a hydrocele and ligation of the testicular artery is likely to result in some degree of testicular atrophy. Microsurgical approaches are believed to decrease morbidity and recurrences to approximately 1 % (Grober et al. 2004). Interventional radiology approaches have also been used, but are reported to have a higher rate of recurrence, approximately 20% (Feneley et al. 1997).

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