Varicocele Anatomy -The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus, which is the network of veins that drain the testicle. -This plexus travels along the posterior portion of the testicle with the epididymis and vas deferens, and then into the spermatic cord. -This network of veins coalesces into the gonadal, or testicular vein. The right gonadal vein drains into the inferior vena cava, while the left gonadal vein drains into the left renal vein at right angle to the renal vein, which then drains into the inferior vena cava.

The small vessels of the pampiniform plexus normally range from 0. 5-1 The small vessels of the pampiniform plexus normally range from 0.5-1.5 mm in diameter. Dilatation of these vessels greater than 2 mm is called a varicocele Etiology The idiopathic varicocele occurs when the valves within the veins along the spermatic cord don’t work properly. This results in backflow of blood into the pampiniform plexus and causes increased pressures, ultimately leading to damage to the testicular tissue.

- Varicoceles usually develop slowly and may not have any symptoms - Varicoceles usually develop slowly and may not have any symptoms. There are most frequently diagnosed when a patient is 15-25 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of infertile males. - 98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein runs vertically up to the renal vein, while the right testicular vein drains directly into the vena cava. Isolated right sided varicoceles are rare, and should prompt evaluation for an abdominal or pelvic mass

A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal malignancy is a definite concern when a varicocele is newly diagnosed in a patient older than 40 years of age. Symptoms Symptoms of varicocele may include: Dragging pain in the scrotum. Feeling of heaviness in the testicle (s) Infertility Atrophy (shrinking) of the testicle(s) Visible or palpable (able to be felt) enlarged vein

Diagnosis 1) Upon palpation of the scrotum, a non-tender, twisted mass along the spermatic cord is felt (it feels like a bag of worms.) The mass may not be obvious, especially when lying down. The testicle on the side of the varicocele may or may not be smaller compared to the other side. 2 ) Varicocele can be reliably diagnosed with ultrasound, which will show dilatation of the vessels of the pampiniform plexus to greater than 2 mm. 3) Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel.

Treatment  Varicoceles may be managed with a scrotal support (e.g. jockstrap, briefs). if pain continues or if infertility or testicular atrophy results, the varicocele may need to be surgically ligated (tied off). Varicocelectomy, the surgical correction of a varicocele. The three most common approaches are:- inguinal (groin), retroperitoneal (abdominal) , and infrainguinal / subinguinal (below the groin)..