Varicocele

Varicocele is the dilation of the pampiniform venous plexus in the scrotum, most commonly on the left side. It arises from incompetent venous valves and increased venous pressure, causing tortuous veins around the testicle.

Most cases are primary (idiopathic); secondary forms may be due to obstruction or tumors. It affects about 15% of men in the general population and is more common among infertile men. Left-sided predominance is typical because the left testicular vein drains into the left renal vein at a right angle.

Clinical presentation varies. Many men have no symptoms. Some notice a dull ache or heaviness in the scrotum, particularly with standing or prolonged activity. In adolescents, varicoceles may be associated with testicular asymmetry or slowed testicular growth.

Diagnosis is based on physical examination and imaging. On exam, a varicocele feels like a soft, creaky, bag of worms structure that worsens with Valsalva and may disappear when supine. Ultrasound with Doppler confirms reflux and assesses testicular size and surrounding structures.

Management ranges from observation to surgery. Asymptomatic cases and those without fertility concerns may be observed. Indications for treatment include painful varicocele, infertility with abnormal semen parameters, or progressive testicular atrophy. Options include microsurgical subinguinal varicocelectomy, open inguinal approaches, laparoscopic repair, or percutaneous embolization.

Outcomes include improvement in semen parameters and potential fertility benefits for selected men. Recurrence and complications such as hydrocele, testicular atrophy, infection, or lymphatic injury can occur and should be discussed with patients.