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.