Varicocele is a dilation and twisting of the veins within the pampiniform plexus that drain the testicles. It is commonly seen in 15-30 year old males and is a cause of infertility in around 40% of infertile males. The left side is more commonly affected due to anatomical factors. Treatment involves surgical ligation of the veins through various approaches like inguinal or retroperitoneal. Other options include embolization or laparoscopy. Surgery is recommended for infertile males with a varicocele to potentially improve semen parameters and fertility chances.

1. VARICOCELE
Ratheesh.R
SLMGNC

2. NORMAL ANATOMYOF
PAMPINIFORM PLEXUS
 Union of multiple spermatic veins from back of testis
and epididymis.
 Ascend along cord infront of the ductus deferens
below the superficial inguinal ring.They unite to form
3-4 veins--inguinal canal—enter abdomen through
deep ring--forms 2 veins which unite—testicular
vein.
 Drain from testes, epididymis and vas deferens-drain
into spermatic veins
 Left spermatic vein drains into renal vein and right
spermatic into inferior vena cava and then into the
rightt renal vein.

3. NORMAL ANATOMY

4. What is varicocele?
 Dilatation and tortuosity of the pampiniform
plexus and so also of the testicular veins.
 Seen commonly in men aged 15-30yrs and
rarely after 40yrs.
 Occur in 15-20% of all males and 40% of all
infertile males.
 Normal small vessels of plexus- 0.5-1.5mm.
Diameter greater than 2mm - Varicocele.

5.  Seen commonly on the left side –5 reasons.
-longer
-enters at right angle to the renal vein
-left testicular artery arching over it
-a loaded sigmoid colon.
- compressed b/w the aorta and SMA.

6. GRADING
 SMALL - identified only by bearing
down i.e, an increase in abdominal pressure.
 MODERATE - identified by palpation w/o
bearing down.
 LARGE - easily identifed by inspection
alone.
 SEVERELY TORTUOUS.

7. Aetiology and types
 1.IDIOPATHIC/PRIMARY – due to
incompetency of valves. 98% occur on the left
side.
 2.SECONDARY- pelvic or abdominal mass.
- L renal cell carcinoma with
tumor thrombus in left vein.
-Nutcracker syndrome- SMA
compressing left vein. Common conditions-
Retroperitoneal fibrosis or adhesions.

8. CLINICAL FEATURES
 Swelling
 Dragging /aching pain in the groin and
scrotum
 “ Bag of worms” feeling
 Scrotum on the affected side hangs down.
 On lying down, it gets reduced.
 Bow sign- hold varicocele b/w thumb and
fingers, patient is asked to bow-reduced in
size.

9.  Cough impulse present
 Long standing cases- affected side testis is
reduced in size and softer.
 Fertility problems.

10. Varicocele and subfertility
 Altered heat exchange mechanism due to
stagnation- hyperthermia-inhibition of
spermatogenesis.
 Increased temperature-increased metabolic
activity-depletion of glycogen storage-injury
of parenchyma of testis-oligospermia.
 Hypoxia, cell dysfunction-low testosterone.
 Maturation arrest-poor spermatogenesis.

11. INVESTIGATIONS
 Venous doppler of the scrotum and groin-
-standing/ valsalva’s manouevre.
 USG abdomen to look for kidney tumours.
 Semen analysis

13. INDICATIONS FOR SURGERY
 American Urological Society recommends that
varicocele treatment should be offered to the
male partner of a couple attempting to
conceive when all of the following are present.
 A varicocele is palpable.
 The couple has documented infertility.
 The female has normal fertility or potentially
correctable infertility.
 The male partner has one or more abnormal
semen parameters or sperm function test
results.

14.  The indications in adolescents- presence of
significant testicular asymmetry (>20%)
demonstrated on serial examinations, testicular
pain, and abnormal semen analysis results.
Very large varicoceles may also be repaired;
however, in the absence of atrophy, this
indication is relative and controversial .

15. TREATMENT
 3 SURGICAL AND 1 NON SURGICAL
PROCEDURE.
1. VARICOCELECTOMY-
The most common approaches are
 inguinal (groin)-easier and safer.
 retroperitoneal (abdominal)
 infrainguinal/subinguinal (below the groin),
 suprainguinal extraperitonial( Palomo’s operation),
 Scrotal approach- grade 4.

16.  2-3 inch incision.
 Ligate the offending
veins.
 Avoid strenuous
exercise for several
days after surgery.
 Apply scrotal
support.

17. Complications
 20% chance of recurrence.
 5% chance of hydrocele
 Damage to testicular artery.
 Infection.
 Hematoma

18. 2. MICRODISSECTION
 Microsurgery (also called microsurgical ligation)
smaller incision is made.
 Cut the skin and fatty tissue. Because muscle is not
cut-less pain and faster recovery.
 The doctor identifies the varicoceles (swollen veins)
through an operating microscope. Large varicoceles
are cut and stapled closed. Smaller varicoceles are cut
and stitched shut.
 Takes less than an hour and recovery time is short.
 Higher success rate, few complications, smaller scar.

19. 3.LAPROSCOPY
 Similar to conventional surgery. Incision made
on abdomen.
 High ligations required.
 Larger incision or more retraction needed.
 Complications more- testicular artery injury
and hydrocele.

20. 4. Coil Embolization, Radiologic
Balloon Occlusion or Radiologic
Ablation:
 Non-surgical procedure.
 Steel coil or silicone balloon catheter is
introduced into a vein below the groin through
a nick in the skin.
 Passed under X-ray guidance.
 Tiny metal coils or other embolizing agents
introduced through the catheter.

21.  No stitches needed.
 Patient can go back in 24hrs.
 Lower rates of complications.
 Disadv- less effective, higher recurrence(5-
11%), danger that the coil could migrate to the
heart and cause death .

24. CONTRAINDICATIONS
 Subclinical varicocele in an infertile person-
controversial.
 Discovery of a varicocele at the time of
vasectomy or vasectomy reversal-relative
contraindication to immediate repair.
 A 6-month delayed repair is recommended -to
allow the development of collateral vessels to
decrease the chance of vascular compromise to
the testicle.