Varicocele
A varicocele is a varicose dilatation of the veins
draining the testis.
Surgical anatomy. The veins draining the testis and
the epididymis form a bulky plexus called the pampiniform plexus. The veins
become fewer as they traverse the inguinal canal and at or near the inguinal
ring they join to form one or two testicular veins which pass upwards behind the
peritoneum. The left testicular vein empties into the left renal vein, the right
into the inferior vena cava below the right renal vein. The testicular veins may
have valves near their terminations but these are often absent. There is an
alternative (collateral) venous return from the testes through the cremasteric
veins which drain mainly into the inferior epigastrics.
Aetiology
Most varicoceles are noticed in adolescence or
early adulthood. The left side is affected in 95
per cent. In
many cases the dilated vessels are cremasteric veins and not part of the
pampiniform plexus.
Obstruction
of the left testicular vein by a renal tumour or after nephrectomy is an
occasional cause of varicocele in middle life and after. Characteristically the varicocele does not decompress
in the supine position.
Clinical
features
Varicocele is more frequent and more
troublesome in hot climates: in all parts of the world, tall, thin men with
pendulous scrota are frequently affected, whereas short, fat individuals are
seldom so. Varicocele does not usually cause symptoms but there may be a vague
and annoying dragging discomfort which is worse if the testis is unsupported by underwear. The scrotum
on the affected side hangs lower than normal (Fig. 68.7) and on palpation, with the patient
standing, the varicose plexus feels like a bag of worms. There may be a cough impulse. If the patient lies down the veins
empty by gravity and this provides an opportunity to ensure that the underlying
testis is normal to palpation. In long-standing cases the affected testis is
smaller and softer than its fellow owing to a minor degree of atrophy. It has
been said that varicocele causes infertility but statistical evidence
supporting the claim is lacking.
VaricoceIe
and spermatogenesis
Of all the possible causes of primary
infertility, oligospermia is one of the most difficult to treat. Because
varicocele is relatively common, some of those with oligospermia have a
varicocele and it is tempting to blame this for the infertility. It is suggested
that the presence of the unilateral varicocele somehow interferes with the
normal temperature control of the scrotum which keeps the testes at some 2.50C
below rectal temperature. Unfortunately, there is little evidence that
varicocelectomy improves semen quality or the rate of conception.
Treatment
Operation is not indicated for varicocele
unless it is
causing symptoms. The simplest procedure is ligation of the testicular vein
above the inguinal ligament where the pampiniform plexus has coalesced into one
or two vessels. Recently this operation has been done laparoscopically. Because
of the presence of plentiful potential collateral veins, recurrence is common
after all types of surgery for varicocele.