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Also known as
Scrotal varices, Pampiniform plexus varicosity, Testicular varicocele
Definition
A varicocele is an abnormal dilation and enlargement of the veins within the pampiniform plexus, located in the scrotum—the loose bag of skin that holds the testicles. These veins are responsible for draining oxygen-depleted blood away from the testicles. The condition arises when blood does not circulate efficiently out of the scrotum and instead pools in these veins, causing them to swell.1 Varicoceles typically develop over time, often beginning during puberty.2 The underlying mechanism is often attributed to malfunctioning valves within the spermatic cord veins. These valves are designed to ensure one-way blood flow back towards the heart; if they fail, blood can backflow and accumulate, leading to venous distension.3 While many varicoceles are asymptomatic, they can sometimes cause testicular discomfort, affect testicular development, or impair fertility by potentially increasing scrotal temperature, causing oxidative stress, or leading to the reflux of toxins.2-4
Clinical Context
Varicoceles are clinically relevant primarily due to their association with male infertility, testicular discomfort or pain, and testicular atrophy.1 They are the most common correctable cause of male factor infertility, affecting a significant percentage of men with primary and secondary infertility.4 Clinically, varicoceles are often identified during routine physical examinations or when a patient presents with fertility concerns.2 The evaluation typically involves a physical examination, where the varicocele is graded based on its palpability and visibility with and without the Valsalva maneuver.4 Grade I varicoceles are palpable only with Valsalva, Grade II are palpable without Valsalva, and Grade III are visible through the scrotal skin.4 Scrotal ultrasound can be used as an adjunctive diagnostic tool, especially when physical examination is difficult or inconclusive, and can help identify dilated spermatic veins (often >2-3 mm in diameter) with reversal of blood flow on Doppler.4
Patient selection criteria for varicocele repair (varicocelectomy) typically include the presence of a clinically palpable varicocele along with one or more of the following: documented male infertility (e.g., abnormal semen parameters), testicular pain attributable to the varicocele, or testicular atrophy (a significant size discrepancy between testicles, particularly in adolescents).1,4 The European Association of Urology guidelines suggest varicocele repair in men with a clinically significant varicocele, oligozoospermia, and/or unexplained infertility of two years or longer.1 Surgery is generally not recommended for subclinical varicoceles (those not palpable or visible but found on imaging) in the context of infertility.1
Surgical procedures for varicocele repair aim to ligate or occlude the dilated spermatic veins. Common approaches include open surgical techniques (inguinal, subinguinal, or retroperitoneal), laparoscopic repair, and percutaneous embolization.1 Microsurgical subinguinal varicocelectomy is often considered the gold standard due to lower recurrence rates and fewer complications, such as hydrocele formation or testicular artery injury.1,4 During this procedure, the surgeon uses a microscope to carefully identify and ligate the dilated veins while preserving the testicular artery, vas deferens, and lymphatic vessels. Percutaneous embolization, performed by an interventional radiologist, involves catheterizing the spermatic vein and occluding it with coils or sclerosing agents; this is often used for recurrent varicoceles.1
Expected outcomes following varicocelectomy include improvement in semen parameters (sperm count, motility, and morphology) in a majority of patients (approximately 70%), and improved conception rates (around 40-60%).1 Semen quality improvements are typically observed 3-4 months post-surgery, becoming final around 6 months.1 For patients experiencing varicocele-associated pain, surgical repair can lead to pain relief. In adolescents with testicular growth retardation, varicocelectomy may allow for catch-up growth of the affected testicle.1