A varicocele is an abnormal enlargement of the pampiniform venous plexus 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 ...

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 cir ...

from the testicles back to the heart. The vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. 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 co ...

. 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.

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.

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 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 beli ...

and mutations in the gene expressing

glutathione S-transferase Mu 1 Glutathione ''S''-transferase Mu 1 (gene name GSTM1) is a human glutathione ''S''-transferase. Function Cytosolic and membrane-bound forms of glutathione ''S''-transferase are encoded by two distinct supergene families. At present, eight dis ...

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, 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 (abdominal using laparoscopic surgery), infrainguinal/subinguinal (below the groin) and

inguinal In human anatomy, the inguinal region refers to either the groin or the lower lateral regions of the abdomen. It may also refer to: * Conjoint tendon, previously known as the inguinal aponeurotic falx, a structure formed from the transversus abd ...

(groin using percutaneous embolization). Possible complications of this procedure include hematoma (bleeding into tissues), hydrocele (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 di ...

, 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 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 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