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varicocele; cirsocele; pampinocele
Etiology:
- left-sided varicoceles are a classic presenting symptom of renal-cell carcinoma & other intra-abdominal tumors
Epidemiology:
- incidence in infertile men is 20-30%
Pathology:
- dilation of the veins of the spermatic cord secondary to incompetent valves in the internal spermatic vein
- impaired drainage of blood into the spermatic cord veins occurs when the patient assumes an upright position
- varicoceles can occur by thrombosis of the testicular vein
- varicoceles can develop in the left hemiscrotum because of blockage & pressure from either tumor thrombosis in the left renal vein or external compression by a mass*
* In most patients, the left testicular vein drains into the left renal vein, whereas the right testicular vein drains directly into the inferior vena cava
* consider inferior vena cava obstruction with right-sided varicocele (compression from a tumor mass)
Clinical manifestations:
- asymptomatic to dull ache with scrotal fullness
- generally left-sided (90%)
- "bag of worms" consistency with palpation of scrotum [1]
- generally diminishes in supine position
- worsens with standing & Valsalva
- negative Prehn's sign, no fever
- chronic disorder
- no transillumination
Laboratory:
1) semen analysis
a) decreased sperm count & motility may be noted
b) abnormal sperm morphology may be noted
2) serum chemistries
a) testosterone is normal
b) gonadotropins LH & FSH are normal
Radiology:
- ultrasonography
- CT of abdomen & pelvis if acute onset of varicocele that does not diminish in supine position (inferior vena cava obstruction)
Management:
1) no treatment in asymptomatic young male
2) NSAIDs & scrotal support [1]
3) if acute onset in older male, consider left renal vein thrombosis from retroperitoneal neoplasm
4) varicocelectomy if infertility is a problem
General
varicose vein (varix)
References
- Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18.
American College of Physicians, Philadelphia 2012, 2015, 2018.
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders,
Philadelphia, 1996, pg 401
- Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed)
Lippincott-Raven, Philadelphia, 1998, pg 274
- Roy CR et al.
Varicocele as the presenting sign of an abdominal mass.
J Urol 1989 Mar 1; 141:597
PMID: 2918600