Varicocele

Abnormal enlargement (varicosity) of the pampiniform plexus (scrotal veins); essentially varicose veins in the scrotum, usually on the left side.

• Most common correctable cause of male infertility. The pooled blood raises testicular temperature, impairing spermatogenesis and potentially causing testicular atrophy if untreated.

• Often asymptomatic and found incidentally (e.g. during infertility evaluation or a routine exam). Classically feels like a soft, nontender 'bag-of-worms' in the scrotum, more pronounced when standing or with Valsalva (especially on the left).
• May present with a dull, aching scrotal pain or heaviness that worsens with prolonged standing and improves when lying down.
• Can lead to testicular growth delay/atrophy in adolescents and reduced fertility in adults (due to increased scrotal temperature affecting sperm production).

1. Physical exam: Best performed with the patient standing and doing a Valsalva maneuver. A varicocele is usually left-sided and collapses when supine. It does not transilluminate (distinguishes it from hydrocele).
2. Use Doppler ultrasound to confirm the diagnosis if exam is equivocal or in preparation for treatment – ultrasound shows dilated pampiniform veins (often >3 mm) with reflux of blood on Valsalva.
3. Always consider the context: an isolated right-sided varicocele or one that remains dilated even when supine is uncommon – this should prompt imaging (e.g. abdominal ultrasound or CT) to rule out a compressive retroperitoneal mass.
4. Differentiate from other scrotal masses: hydroceles (fluid around testis that transilluminates), spermatoceles (epididymal cysts, separate and usually small), inguinal hernias (bowel protrusion into scrotum, often reducible), and testicular tumors (firm intratesticular mass that does not change with position).

1. If no symptoms or fertility issues: conservative management (observation, scrotal support garments, NSAIDs for occasional discomfort). Many varicoceles are harmless and need no intervention unless they cause problems.
2. Indications for active treatment include infertility, testicular atrophy (in adolescents), or chronic pain. In these cases, varicocele repair can improve sperm parameters and relieve symptoms.
3. Treatment options: surgical ligation (varicocelectomy, often microsurgical) or percutaneous embolization of the internal spermatic vein. These procedures tie off or block the enlarged veins to reroute blood flow. Successful treatment often leads to improved testicular size in youth and better semen quality in adults.

• "Bag of worms" scrotal feel = classic varicocele finding (dilated, tortuous spermatic veins).
• Left-sided ~90%: due to left testicular vein anatomy (longer course and 90° drainage into left renal vein with higher pressure from the nutcracker effect).

• Rapid onset or right-sided varicocele (especially in an older patient), or a varicocele that does not reduce when supine, is atypical → think of a retroperitoneal mass (e.g. a renal tumor compressing venous drainage) and investigate further.

1. Scrotal mass noted or male infertility workup → examine standing with Valsalva.
2. If soft left scrotal mass that feels like worms and collapses when supine → Varicocele likely (confirm with Doppler ultrasound if needed).
3. If varicocele is isolated on right side or doesn't collapse supine → obtain abdominal imaging to rule out a retroperitoneal mass (e.g. RCC).
4. Normal fertility and minimal symptoms → observe (no treatment necessary).
5. Infertility, significant pain, or adolescent with testicular atrophy → proceed to varicocelectomy or embolization to repair the varicocele.

• Adolescent boy with a left scrotal mass that feels like a bag of worms on exam (increases with standing/Valsalva, decompresses when supine) and a slightly smaller left testis → varicocele.
• 30-year-old man evaluated for infertility with a history of 1–2 years of failed attempts. He has a dull ache in the left scrotum, and exam reveals dilated veins in the left scrotum that enlarge with Valsalva. Semen analysis shows low sperm count and motility → varicocele contributing to male infertility.