A varicocele is an abnormal enlargement of the

pampiniform venous plexus The pampiniform plexus (from Latin ''pampinus'', a tendril, + ''forma'', form) is a venous plexus – a network of many small veins found in the human male spermatic cord, and the suspensory ligament of the ovary. In the male, it is formed by th ...

in the scrotum. This plexus of

vein Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...

s drains

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...

from the

testicle A testicle or testis (plural testes) is the male reproductive gland or gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testes are to produce both sperm and androgens, primarily testostero ...

s back to the heart. The vessels originate in the abdomen and course down through the

inguinal canal The inguinal canals are the two passages in the anterior abdominal wall of humans and animals which in males convey the spermatic cords and in females the round ligament of the uterus. The inguinal canals are larger and more prominent in males. T ...

as part of the

spermatic cord The spermatic cord is the cord-like structure in males formed by the vas deferens (''ductus deferens'') and surrounding tissue that runs from the deep inguinal ring down to each testicle. Its serosal covering, the tunica vaginalis, is an exten ...

on their way to the

testis A testicle or testis (plural testes) is the male reproductive gland or gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testes are to produce both sperm and androgens, primarily testostero ...

. Varicoceles occur in around 15% to 20% of all men. The incidence of varicocele increase with age.

Signs and symptoms

Varicocele might be noticed as soft lumps, usually above the testicle and mostly on the left side of the

scrotum The scrotum or scrotal sac is an anatomical male reproductive structure located at the base of the penis that consists of a suspended dual-chambered sac of skin and smooth muscle. It is present in most terrestrial male mammals. The scrotum cont ...

. Right-sided and bilateral varicocele does also occur. Men with varicocele can feel symptoms of pain or heaviness in their

. Large varicoceles present as plexus of veins and may be described as a "bag of worms". Varicocele is sometimes discovered when investigating the cause of

male infertility Male infertility refers to a sexually mature male's inability to impregnate a fertile female. In humans it accounts for 40–50% of infertility. It affects approximately 7% of all men. Male infertility is commonly due to deficiencies in the semen, ...

Cause

There are three main theories as to the anatomical cause; the first has to do with the geometry of the veins, wherein the vein on the left side connects to the larger outflowing vein at a right angle, which tends to fail; the second is that valves that are supposed to prevent backflow fail (venous insufficiency); the third is due to excessive pressure in upstream arteries, created by

nutcracker syndrome The nutcracker syndrome (NCS) results most commonly from the compression of the left renal vein (LRV) between the abdominal aorta (AA) and superior mesenteric artery (SMA), although other variants exist. The name derives from the fact that, in the ...

Pathophysiology

Often the greatest concern with respect to varicocele is its effect on male fertility. The relationship between varicocele and infertility is unclear. Some men with the condition are fertile, some have sperm that are normal in shape and move normally but are compromised in function, and some have sperm with abnormal shapes or that do not move well. Theories as to how varicocele affects sperm function include damage via excess heat caused by the blood pooling and

oxidative stress Oxidative stress reflects an imbalance between the systemic manifestation of reactive oxygen species and a biological system's ability to readily Detoxification, detoxify the reactive intermediates or to repair the resulting damage. Disturbances ...

on sperm.

Tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...

and mutations in the gene expressing glutathione S-transferase Mu 1 both put men at risk for infertility; these factors may also exacerbate the risk that varicocele will affect fertility.

Diagnosis

Following discovery of the sign of swelling comprising a mass, varicocele can be confirmed with

scrotal ultrasound Scrotal (or transscrotal) ultrasound is a medical ultrasound examination of the scrotum. It is used in the evaluation of testicular pain, and can help identify solid masses. Indications Although the development of new imaging modalities such as c ...

, which will show dilation of the vessels of the pampiniform plexus to be greater than 2 mm. File:trans varicocele.tif, Varicocele in ultrasound (left: testicle) File:Varicocele.png, Varicocele

Imaging

Manual examination of scrotum is required for proper interpretation of ultrasound images. During ultrasound examination, diameters of veins in pampiniform plexus are measured and regurgitation is measured. The subject is then instructed to stand up and

Valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can ...

is performed. The diameter is then measured and changes in blood flow direction is recorded to assess any regurgitation.

Treatment

Wound after microsurgical varicocelectomy

The two most common surgical approaches are

retroperitoneal The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on their ...

(abdominal using

laparoscopic surgery Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medl ...

), infrainguinal/subinguinal (below the groin) and inguinal (groin using

percutaneous {{More citations needed, date=January 2021 In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using ...

embolization Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin (pathological), in which sense it is also called embolism, for example a pulmonary embolism; or it may be artificially induced (t ...

). Possible complications of this procedure include

hematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...

(bleeding into tissues),

hydrocele A hydrocele is an accumulation of serous fluid in a body cavity. A hydrocele testis, the most common form of hydrocele, is the accumulation of fluids around a testicle. It is often caused by fluid collecting within a layer wrapped around the testi ...

(accumulation of fluid around the affected testicle),

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...

, or injury to the scrotal tissue or structures. In addition, injury to the artery that supplies the testicle may occur, resulting in a loss of a testicle.

Prognosis

Whether having varicocele surgery or embolization improves male fertility is controversial, as good clinical data is lacking. There is tentative evidence that varicocelectomy may improve fertility in those with obvious findings and abnormal sperm; however, this has a

number needed to treat The number needed to treat (NNT) or number needed to treat for an additional beneficial outcome (NNTB) is an epidemiological measure used in communicating the effectiveness of a health-care intervention, typically a treatment with medication. The ...

of 7 for varicocelectomy and 17 for embolization. There are also studies showing that the regular surgery has no significant effect on infertility. A 2012

Cochrane review Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...

(updated in 2021) found tentative but unclear evidence of improved fertility among males treated for varicocele. Evidence for

sclerotherapy Sclerotherapy (the word reflects the Greek ''skleros'', meaning ''hard'') is a procedure used to treat blood vessel malformations (vascular malformations) and also malformations of the lymphatic system. A medicine is injected into the vessels, wh ...

is unclear as of 2015.

Epidemiology

Around 15% to 20% of all adult males, up to 35% to 40% of men who are evaluated for male infertility, and around 80% of men who are infertile due to some other cause, have varicocele.

References

{{authority control Andrology Male genital disorders Scrotum Vascular diseases